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S, H 



Voi,. III. SEPTEMBER, 1892. No. 1. 



THE REVIEW 



OF 



Insanity # Nervous Disease. 



A Quarterly Compendium of the Current Literature 
of Neurology and Psychiatry. 



EDITED BY 

JAMES H. MCBRIDE, M. D., 

MILWAUKEE, WIS. 
ASSOCIATE EDITORS: 
LANDON CARTER GRAY, M. D., New York ; C. K. MlELS, M. D., Philadelphia ; 
EUGENE RIGGS, M D., St. Paul, Minn. ; W. A. JONES, M. D., Minneap- 
olis, Minn.; H. M. BANNISTER. M. D„ Hampton, Ct.: D. R. 
BROWER, M. D., H. M. LYMAN, M. D., J. G. KlERNAN, M. D., 

Archibald Church, M. D., Sanger Brown, 
M. D., S. V. Clevenger, M. D., 

Chicago. 



$200 PER YEAR. SINGLE NUMBERS, 50c 



MILWAUKEE, WIS.: 
RIVERSIDE PRINTING CO., PRINTERS, 

1892. 




INDEX. 



Original Article — Acute Myelitis, 

By Sanger Brown, m. d., Chicago. 

Neurological — 


- 3-14 


Anatomy and Physiology, - 
Pathology and Symptomatology, 
Therapeutics, .'-..-- 
Surgery and Traumatic Neuroses, 


- 16-19 
19-61 

- 61-73 
73-89 


Psychological — 




Pathology and Symptomatology, 


- 89-108 


Reviews, New Books, Etc., 


108-115 


Pamphlets and Reprints, 
Miscellaneous, y^Xh A LO^t^^w- 


- 115-117 
- 117-118 


f MAR -6 1914 J 




\^J FB^/ 





jjBRAgg 

ACUTE MYELITIS. 

By Sanger Brown, M. D., Chicago. 



Professor of Forensic Medicine and Hygiene, Rush Medical College; Pro- 
fessor of Diseases of the Mind and Nervous System, Post-Graduate 
Medical School; Late Acting Medical Superintendent of the 
Bloomingdale Asylum of New York; Member of the 
London Neurological Society, Etc., Etc. 



A pretty large proportion of medical students who 
graduated in this country from ten to fifteen years ago, did 
so without having been taught anything very definite on 
the subject of myelitis. It is true that most of the works 
on Practice of Medicine contained a few paragraphs or 
pages on paraplegia, but myelitis had not attained the 
dignity of a clearly recognized and important disease. 
This accounts for the fact that to-day here in Chicago so 
many cases are not correctly diagnosed till they happen to 
fall under the eye of a neurologist. 

In a large proportion of cases the disease is pretty easily 
recognized, if only the symptoms are studied in the light 
of modern anatomical and physiological views pertaining 
to the nervous system. 

Compared with organic disease of other organs and 
tissues, organic disease of the central nervous system is 
very rare, but among these latter, myelitis is comparatively 
frequent, and the comparative frequency would be very 
much increased if that inflammation of the cord were 
included, which for some reason confines itself to the grey 



4 ACUTE MYELITIS. [Sept., 

matter of the cord — polionyetitis — and is mainly observed 
in young children, for which reason it has been termed the 
essential spinal paralysis of children. 

Reference is only had in this paper to the variety of 
myelitis which occurs mainly in adults and involves all 
tissues of the cord without regard to their functions or 
structure — a non-systemic or non-discriminating myelitis 
commonly described also as a transverse myelitis, because a 
longer or shorter segment of the cord is usually completely 
invaded. Cases produced by trauma or the extension 
of disease from contiguous structures are excluded, because 
in them diagnosis is not so difficult. 

Any cause which reduces the vitality of the tissues favors 
the development of this disease ; thus syphilis, which is 
one of the most clearly recognized and most potent devital- 
izers, is found to have preceded myelitis in a large propor- 
tion of cases. It was admitted in two-thirds of the cases of 
which I have taken notes, but in none of them were there 
any of the usual active manifestations of syphilis present, 
nor had there been, according to the statements of the patients, 
within two years from the onset. Exposure to wet and 
cold is commonly reckoned among the causes, but I think 
investigation will generally reveal the fact that the vitality 
had previously been markedly reduced by some other dis- 
ease or by fatigue, or both. The vitality of the cord is so 
much reduced in Locomotor Ataxy that one might expect 
myelitis to occur quite frequently in that disease, but, while 
a number of instances of such occurrence are on record, 
they are by no means frequent. 

The influence of heredity may be neglected, but age and 
sex have a decided bearing. A large majority of the cases 
occur in males between the ages of 20 and 40, which would 



1892.] BY SANGER BROWN, M. D. 5 

tend strongly to emphasize the importance of activity and 
exposure as factors in the etiology. 

The symptoms are extremely variable. Those relating 
to the onset are of much importance, because it is only 
at this stage that treatment can be of much benefit in 
arresting the further development of the pathological 
process. 

In many cases slight premonitory symptoms precede the 
more marked symptoms for several days. If questioned 
closely the patient will remember these. They may consist 
of motor or sensory disturbance, or both. Motor dis- 
turbance alone is more frequent than sensory disturbance 
alone, and about as frequent as both together. As the dis- 
ease is in the vast majority of cases confined to the dorsal 
region the symptoms refer mainly to the lower extremities, 
the bladder and rectum. 

These early motor symptoms may consist of a steadily 
increasing weakness of the legs, sometimes more noticeable 
in one than the other, so that the patient finds himself 
unaccountably clumsy and the legs feel heavy, or he may 
have periods of considerable weakness, lasting only for a 
few minutes or a few hours, from which he almost or quite 
completely recovers. What has been said of the muscles 
of the legs applies equally well to the detrusor muscle of 
the bladder. From the nature of the case variations in the 
power of the muscles concerned in the propulsion of the 
contents of the bowels cannot be clearly demonstrated, but 
constipation where the bowels had previously been regular 
is often observed. 

Pain cannot fairly be reckoned among the premonitory 
symptoms, and neither can alterations in the senses of 
touch or pain. Most common among these early sensory 



6 ACUTE MYELITIS. [dept., 

disturbances are prickling, pins and needles, formication 
and numbness, as if the shoe were laced too tightly. These 
may remit more or less completely before they become 
established or steadily progressive. 

These premonitory symptoms are rarely, if ever, accom- 
panied by any general symptoms, though for some unex- 
plained reason several of my patients have volunteered 
that for a day or two prior to the active outbreak there had 
been unnatural somnolence and the sleep at night had 
seemed to be unnaturally heavy. I have not seen this 
noted elsewhere and should think it must be a mere 
coincidence. 

Though the symptoms above described may be arrested 
without advancing much farther, and after a few weeks 
begin to disappear, it more often happens that at a certain 
point they commence rapidly to progress so that in a few 
hours both motion and sensation are seriously impaired, if 
not entirely lost. In a considerable number of cases pre- 
monitory symptoms are entirely absent. This activity of 
the diseased process may be, and often is, attended with 
some general disturbance, rarely severe, but when there is 
only comparatively slight disturbance, vomiting — not severe 
or protracted necessarily — is more likely to occur than in 
diseases where the main pathological process is not situated 
in the central nervous system. This occurs when the 
lesion is confined to the dorsal region of the cord remote 
from the centres concerned in the mechanism of vomiting. 
There is, after all, nothing distinctive enough in the general 
disturbance to throw much light upon the question of 
diagnosis. During the premonitory period the cutaneous 
reflexes and the knee jerks are usually, or at least often, 
exalted — and sometimes there is ankle clonus, but during 



1892.] BY SANGER BROWN, M, D. 7 

the period of activity, especially if this be severe, even 
though the reflex arc be not included in the pathological 
process, all reflexes may be absent, but if that part of the 
reflex arc situated in the cord, that is, the lumbar enlarge- 
ment, escapes, they will soon return and become greatly 
exaggerated. I have never known the cremasteric reflex 
to return in a case where dorsal myelitis had followed 
syphilis. There will usually develop a hypersesthetic zone 
at the upper limit of the lesion, and in mild cases the patient 
may describe it simply as a girdle sensation. It is not 
invariably present. 

The permanent symptoms need not occupy much space. 
In cases of much severity the legs are usually spastic to 
some extent and unless splints are used contractions occur. 
There may be priapism at first which may persist for weeks, 
but impotence from the first is far more common. There 
will be no atrophy unless the lumbar enlargement is in- 
volved, nor with ordinary care are bad sores likely to form. 

The two cases detailed below illustrate the mild and 
severe types of the disease. 

Case I. — A. D. was referred to me Sept. 15. Patient 
admits syphilis three years ago; states that for the 
past three weeks he has suffered from obstinate con- 
stipation, having been very regular previously, and one 
week ago had difficulty in micturition ; the stream 
became small and weak and he could not force it as usual ; 
three days ago this had progressed to complete retention 
which has continued down to the present. Two days ago 
noticed for the first time weakness of the right leg which 
has steadily increased ; can walk well on a smooth floor 
but the knee even then occasionally gives way and the leg 
feels heavy and awkward. The only alteration in sensation 



8 ACUTE MYELITIS. [Sept., 

has consisted in an unnatural feeling of warmth from the 
cold sheets when getting into bed. There has been no pain 
whatever and no disturbance of the general health. 

Examination revealed greatly exaggerated knee-jerks 
and ankle clonus alike on both sides, and loss of the plan- 
tar, cremasteric and abdominal reflexes. There was slight 
weakness of the left leg. No disturbance of sensation 
could be made out excepting that a test tube filled with ice 
water and applied to the leg did not feel cold. Heat 
appeared to be normally appreciated. 

There was no further advance of the symptoms, patient 
having been immediately put to bed and kept lying in the 
prone or lateral position with alternately hot and cold 
applications to spine, small doses of calomel and light diet. 
The spinal applications were discontinued on the fifth day, 
though rest and a light diet were still enjoined. Patient 
was impressed thoroughly with the importance of using the 
catheter properly, and, as often happens in these cases, a 
small soap or glycerine suppository would usually produce 
a satisfactory movement of the bowels. 

In five weeks from the arrest strength began to return in 
the legs and in three months he resumed work on his train, 
but the right leg was still somewhat awkward. He dis- 
pensed with the catheter but it took him longer to urinate 
than formerly and there was some constipation. A few 
months later he married, soon after which he became worse 
than ever, and while the symptoms were arrested by a rep- 
etition of the former treatment, several months later 
not much improvement had taken place. 

Case II. — A. C, a gentleman of 30, had syphilis at 28, 
and while taking his accustomed horseback ride after busi- 
ness hours July 18th, was seized with violent pains in the 



1892.] BY SANGER BROWN, M. D. 9 

back, which soon subsided when he had checked his horse's 
speed, so that he rode slowly home with comfort and slept 
well. He had noticed for five days prior to this, however, 
that his knees were weak as he came down stairs in the 
morning, but this disappeared after he had walked a little. 
The morning following the horseback ride above referred to, 
weakness was more marked than before and persisted, and 
at 10 a. M. intense pains set in in the lumbar region which 
could not be relieved by posture. At about 1 p. m. there 
was noticed marked impairment of sensation extending 
from below upward to the crest of the ilium on each side. 
By 5 p. m. all power of motion in the legs was lost and 
nearly all sense, of feeling had vanished in them. There 
was retention of urine and faeces, and passage of the 
catheter caused no sensation. There was a marked 
hypersesthetic girdle at the upper limit of the lesion. 

Febrile movement varying from 100 to 102 degrees 
supervened, and that with the lumbar pain lasted about 
ten days, when both subsided together and the general 
health became good. In two or three weeks from the onset 
intense spastic symptoms supervened, with priapism, and 
pins and needles sensations appeared in the feet, but this 
last only lasted a few days. 

Six months later not the least power of voluntary move- 
ment had returned in the lower extremities, and there was 
still no improvement in the condition of the bladder and 
rectum. The sense of touch was absent below the level of 
the lesion, but the pain and temperature senses were 
present, though impaired, notably from above downward, 
completely disappearing at a point about midway between 
the ankle and knee. 

As the spastic symptoms in the legs were very trouble- 



10 ACUTE MYELITIS. [Sept., 

some, splints were applied which could be locked at the 
knee in any desired position, and the patient was 
encouraged to ride out daily, while passive movement and 
massage were regularly and thoroughly applied. Some 
degree of voluntary movement soon appeared which 
slowly extended and increased, so that a few months later 
by the aid of crutches and a wheel chair patient success- 
fully resumed his business duties. The catheter has still 
to be used and the bowels require artificial aid, and in a 
case so severe as this one it is not to be expected that they 
will resume their normal function. 

This case did well without electricity, excepting that a 
nurse at one time applied faradization to the legs with the 
result of aggravating the spasm. This so predjudiced the 
patient against its use that he was not anxious to have 
anything more to do with the remedy and it was accord- 
ingly dispensed with. 

The patient's condition at present is essentially that of 
an advanced case of spastic paraplegia, for which it might 
readily be taken if the history were not taken into account. 

The symptoms are due to injury or destruction of the 
cord, and in transverse dorsal myelitis this is mainly 
limited to its conducting elements. This cuts off communi- 
cation with the brain, which accounts for the disturbance 
of motion and sensation. The extension of the inflamma- 
tion to the surface of the cord with the consequent irrita- 
tion of the meninges and posterior nerve roots, accounts for 
the girdle sensation at the upper limit of the lesion. When 
the lumbar enlargement is involved the cells of the lower 
segment suffer; these preside over the nutrition of the 
muscles, which then atrophy ; the reflex arc is likewise 
interrupted and the reflexes are absent. It is true that 



1892.] BY SANGER BROWN, M. D. 11 

some cells are destroyed when the inflammation is confined 
to the dorsal region, but the functions of the muscles with 
which they are connected are so indefinite that no symp- 
toms of importance result from their destruction. 

Hysterical paraplegia is quite frequently mistaken for 
paraplegia due to myelitis, but a few days' observation will 
usually suffice to distinguish between the two. Hysteria is 
much more frequent in females and myelitis in males. The 
upper boundary of disturbed sensation extends straight 
round the trunk in myelitis, its plane lying at right angles 
to the axis of the trunk, while in hysteria the boundary 
diverges from the pubes, leaving the abdomen normally 
sensitive and the back more or less insensitive as far up as 
the lower angles of the scapulas. In hysteria, the reflexes 
may be exaggerated, they are never absent, the knee 
jerk is sometimes accompanied by a general jerky contrac- 
tion of many of the flexors, and there may be a spurious 
foot clonus. It is true, there may be retention of urine, 
and constipation and paralysis without atrophy in both 
cases ; of course, there is never a true atrophy in hysteria, 
but there may be considerable disuse atrophy. Retention 
in hysteria is not usually very persistent, whereas the 
reverse is true of myelitis. 

Hemiparaplegia would almost never be due to an acute 
myelitis. 

The immediate danger to life is not great unless the 
disease reaches the medulla oblongata, which it rarely does, 
and, indeed, the remote danger is not great if proper care 
is bestowed upon the bladder and bowels, where the 
paralysis of these organs is permanent. Unless there is 
considerable atrophy, restorative measures should not be 



12 ACUTE MYELITIS. [Sept., 

abandoned until a year or more had transpired without 
improvement. 

The treatment may be divided into two parts : First, the 
measures employed to arrest or modify the process during 
the period of development ; and, second, measures directed 
to restoration of deranged functions. 

Of main importance in securing the first object is com- 
plete rest, and a prone or lateral decubitus in order to assist . 
as much as possible the circulation in the cord ; this object 
should be further promoted by alternate hot and cold appli- 
cations and dry cups along the affected regions of the spine. 
Small doses of calomel may be given frequently for a few 
days and a light but nutritious diet should be adhered to. 
No stimulants should be allowed. A few moments of rest 
on the back will often afford great relief without probably 
doing material harm. When feasible I have placed a 
mound of pillows and bedding under the abdomen so as 
to make the dorsal region the highest part of the body. I 
believe in a few cases by the early adoption of these 
measures, rigidly enforced, I have arrested the inflammatory 
process. And while in the cases of rapid onset no imme- 
diate benefit appears to result from any kind of treatment, 
yet it is not unreasonable to assume that by a thorough use 
of the measures described, the intensity of the process may 
be so far modified as to render the degree of subsequent 
improvement much greater than might have been possible 
otherwise. The treatment would likewise tend to limit 
extension of the inflammation. Enemata for the bowels and 
a catheter for the bladder have very commonly to be 
employed. 

After a severe attack there will, at best, be a stationary 
period lasting several weeks, during which any measures * 



1892.] BY SANGER BROWN, M. D. 13 

directly calculated to promote recovery cannot properly be 
employed. But during this period attention to the bladder 
and bowels is of the utmost importance, and as they 
are likely to require artificial aid in the performance of 
their functions for the remaider of the patient's life, and as 
neglect, especially of the bladder, is the most frequent cause 
of death in these cases, the patient should be given a 
thorough course of instruction in the art of keeping these 
organs in a healthy condition. At the same time, besides 
measures to keep the general health in a good condition, 
light massage and exercise of the joints should be regularly 
practiced in order to keep the parts healthy, in anticipation 
of the time when enough regeneration shall have occurred 
at the focus of injury in the cord to permit impulses to and 
from the brain to pass. 

It is somewhat doubtful if measures can be directly 
applied to hasten regeneration of the cord, but it is a 
rational assumption that the process may be favorably 
affected by bringing the general health to the highest 
point. Whatever may be its usefulness, patients in this 
country at the present time pretty generally demand 
electricity in some form if they have paralysis. As well 
authenticated cases have been recorded where myelitis has 
been produced by the passage of a strong, interrupted gal- 
vanic current through the cord, it is safe to conclude that 
a direct effect may be produced by galvanism, and though 
it w T ould be difficult to demonstrate just what amount 
of electricity would be necessary to produce the most bene- 
ficial amount of stimulation, it is highly probable that some 
degree of electrical stimulation would promote the process 
of regeneration. I commonly apply from 25 to 30 m. a. 
over the seat of the lesion, either daily or every alternate 



14 ACUTE MYELITIS. [Sept., 

day, placing the electrodes a few inches apart and moving 
them slowly up and down along the spine for about ten 
minutes. 

If the spastic symptoms are not too severe and there is 
some sensory disturbance, faradism over the whole surface 
of the legs will usually give the patient a sensation as if 
he had been using his limbs, which is very gratifying to 
him. Perhaps cerebral centres are in this way thrown 
into activity which are intimately connected with those 
more immediately concerned in the outgoing impulse, 
whereby this latter is so far increased that more of it forces 
its way through defective conducting paths, with some tem- 
porary improvement in voluntary movement. Such tem- 
porary improvement certainly follows faradization of the 
legs in some cases, whatever the true explanation may be. 
And in a condition so tedious and so obstinate, when our 
resources of treatment are so limited, we should welcome 
remedies which produce even a very slight benefit, if only 
for the purpose of sustaining the courage of our patient 
till use and custom has finally rendered his affliction less 
intolerable. 

No time must be lost in the application of splints when 
spastic symptoms come on in order to prevent permanent 
contractions. They should have a hinge at the knee so they 
can be locked in any position, in order that the patient may 
so adjust them as to be most suitable for riding, lying or 
walking, as the case may be. Marked improvement often 
sets in when by the aid of these devices the patient is 
encouraged to go out of doors regularly again, and give his 
attention to some suitable occupation. 

The foregoing refers exclusively to a transverse myelitis 
confined to the dorsal region. The alterations which 
would be presented by an extension of the process can 
be readily inferred by recalling the anatomy and physi- 
ology of the parts of the cord involved. 



1892.] ' TRANSLATORS. 15 



TRANSLATORS. 



ITAIJAX. 

H. M. Bannister, m. d. 

F. H. PRITCHARD, M. I)., XOKWAI.K, OHIO. 

( ; E R M A N . 

g. j. kaumheimer, m. d., milwaukee. 
Clement Venn, m. i>.. Chicago, 
h. m. bannister, m i). 
Jos. Kahn, m. P., Milwaukee. 

ROUMANIAN, RUSSIAN, DUTCH AND PORTUGUESE. 
F. H. Pritchard, M. D., Nor walk, Ohio. 

FRENCH. 
J. G. KlEKNAN, M. D., CHICAGO. 

SPANISH. 
Horace M. Brown, M. d., Milwaukee. 

F. H. PRITCHARD, M. D., NORWALK, OHIO. 

SWEDISH, DANISH AND NORWEGIAN. 

M. NELSON VOLDING, M. D., Asst. Physician State Hospital for Insane, 

Independence, Iowa. b 
f. h. pritchard, m. d., norwalk. 



16 NEUROLOGICAL. [Sept., 



NEUROLOGICAL 



ANATOMY AND PHYSIOLOGY. 



Cerebral Circulation During Psychical Activity 
and Under the Action of Certain Intellectual Poisons. 
— De Sarlo and Bernardini, Riv. Sperimevitale, 1891 and 
1892. The authors, after reviewing the theories and litera- 
ture of the subject, report experiments and observations 
made upon a patient of a certain degree of intelligence 
who had a fracture of the skull that permitted instru- 
mental registration of the movements of the brain. The 
object of their investigations was to determine the relations 
existing between the cerebral pulse and the emotions. They 
found that in all emotional conditions there was an increase 
of the cerebral volume and of the height of the pulsations. 
The physical pain produced by the electric current always 
caused vasal spasm, while the pain induced by other 
means either did not specially modify the circulation, or 
the modification occurred at the same time with the other 
emotions. The form of the pulsation was not modified by 
slight emotional disturbances, while those of greater inten- 
sity produced anacrotism. Only especial forms of emo- 
tional disturbance produced a special type of pulse inter- 
mediate between anacrotism and catacrotism, which they 
term ad altipiano, and which they consider as a sort of 
transition form due to two opposing vasal reflexes. They 
also experimented by administering to the subject certain 
drugs producing decided effects upon the cerebral circula- 
tion in the way of ischsemia, hypersemia, etc., in order to 
ascertain the effect upon the cerebral and peripheral pulse 
by the special emotions when under the influence of these 
drugs. They conclude that the manner of reaction of the 
cerebral circulation produced by emotions is not altered by 
the effects of these agents, and the changes in the cerebral 
circulation induced by the emotions are of the nature of 
reflexes, not subject to modification by pre-existing condi- 
tions. As regards the peripheral circulation, they find it 
modified variously by emotional conditions and that it is 



1892.] ANATOMY AND PHYSIOLOGY. 17 

not a reliable index of the quality of mental activity. The 
authors do not find in this discordance between the effects 
of the emotions and the actions of drugs affecting the cir- 
culation, any very good support for the theory that the dis- 
turbances of the latter are the active agents in producing 
the psychosis. They see, rather, an evidence that the action 
of these drugs is due to special chemical effects, the real 
nature of which is still very obscure or altogether unknown. 
They conclude by offering the suggestion, that as the 
psychic phenomena observed by them in their subjects were 
due to a chemical intoxication, and not to circulatory distur- 
bances, thus many forms of mental disease have for their 
cause, instead of cerebral hypersemia or anaemia, some in- 
toxication, of the real nature of which we are still in 
ignorance. H# M< bannister. 

On the Physiology of the Labyrinth. — Dr. A. Kreidl 
reports experiments made upon deaf mutes with the object 
of testing the theory of Mach and Breuer in regard to the 
physiological functions of the labyrinth. According to this 
theory the function of the semicircular canals is the cogni- 
tion of rotation. When the head is moved, the fluid in the 
canals, by reason of its inertia, flows, relatively, in a reverse 
direction and thus acts on the terminal nervous apparatus 
of the canals, enabling us to recognize our changed relation 
to the horizon. The otoliths, on the other hand, are in- 
tended to take cognizance of our relation to space. By 
their movements they act on the nerve terminations upon 
which they rest, and by the correspondence of their position 
with the three dimensions of space impress upon our con- 
sciousness each change of position. The experiments of 
James upon deaf mutes were defective, as James depended 
on the vertigo resulting from rotation. This symptom 
is purely subjective and varies with the subject. Kreidl's 
experiments w r ere based upon the fact that rotation with 
closed eyes, in the normal subject, is attended by quick, 
nystagmus-like vibration of the globe which can be felt 
through the closed lids. Among 50 physicians tested 
this phenomenon was subnormal only once. Among 109 
deaf mutes, each being tested several times, immobility of 
the eye during rotation was found 55 times. In 34 the 
movements were normal ; 20 were rejected on account of 
abnormal eye movements. Autopsies on deaf mutes show 
that about 56 per cent have an affection of the semicircular 



18 NEUROLOGICAL. [Sept., 

canals. The coincidence of these figures justify, in the 
author's opinion, the theory stated. As a test of the func- 
tion of the otoliths, the author adopted the fact that if we 
pass over a curved path with proper speed, vertical objects 
appear leaning. This he explains as the resultant of the 
vertical, horizontal and centrifugal forces acting on the 
otoliths. The test was made with a crude sort of caroussel, 
in which the person examined was screened from surround- 
ing objects and faced a dial bearing a vertical hand. On 
rotating this contrivance at a proper speed, the person ex- 
amined was instructed to keep the indicator vertical during 
rotation. Experiments on 71 physicians showed that the 
indicator was deflected to an average of 8J degrees in 70 
cases. Among 62 deafmutes, 13 did not deflect the indi- 
cator. In these persons the eye movements had also been 
absent in the first test. K. assumes a combination of dis- 
ease of the canals and otoliths. Lesions of the otoliths are 
much rarer than lesions of the canals, and besides this we 
have accessory apparatus for the realization of our position 
in space. Other minor tests, in some of which vision was 
eliminated, corroborated the results obtained, that deaf- 
mutes have neither the normal power of recognition of 
their relation in space nor the same power of normal ad- 
justment to changes in such relation. Kreidl therefore sug- 
gests the adoption of Breuer's suggestion that these organs 
be called the organs of "static sense." — [Prog. Med. Wochensch., 

JNO. J 4, lOoZ.) G , j. KATTMBEIMKR. 

Some Contributions to the Muscular Sense. — Dr. 
Preston read a paper before the American Neurological 
Association with the above title. 1. The posture sense is 
composed of afferent impulses derived from muscles, ten- 
dons, articulations and their coverings, and bones. 2. It 
is independent of, and separable from, general tactile sensi- 
bility, and probably could be distinguished from the other 
members of this class, as the pressure sense, for example. 
3. The course of these impulses through the cord is 
almost certainly by means of the posterior columns. 4. 
They probably pass into the corpus restiform and the cere- 
bellum. 5. In all probability they pass through the anterior 
portion of the posterior third of the posterior limb of the 
internal capsule, occupying an intermediate position 
between the motor and sensory fibers in this region. 6. 
Without positive data on either side it would seem most 



1892.] ANATOMY AND PHYSIOLOGY. 19 

probable that the centre, for the posture sense is located in 
one of the cell-layers, of the motor cortex. — (Med. Record, 
July 30, 1892.) B . m. cables. 

The Strle Medullares of the Medulla Oblongata. 
— It is believed by many anatomists that the striae 
medullares, or striae acusticae of the medulla, are connected 
with the roots of the auditory nerve. Bechtezeff disputed 
this view some time ago on the ground that, at all events in 
man, the development of the striae medullares is much later 
than that of the auditory nerve. He has recently pub- 
lished another paper in which he gives an account of the 
course of striae medullares so far as he has been able to 
trace them anatomically. They arise in the white sub- 
stance of the cerebellum close to the flocculus and serve as 
commisural fibers for the basal portion of the cerebellum, 
emerging from the cortex of the convolution of the flocculus. 
The fibers first follow the inner basal surface of the flocculus, 
ascending on the margin of the cerebellum which sur- 
rounds the restiform body, and then reach the lateral 
margin of the fourth ventricle. — {Lancet, July 23, 1892.) 



B. M. (JAPLES. 



NEUROLOGICAL 



PATHOLOGY AND SYMPTOMATOLOGY. 



A Contribution to the Pathology of Arrested Cere- 
bral Development. — Dr. Sachs read a paper before the 
American Neurological Association with the above title. He 
said the gross lesions of childhood received much attentiori 
of late years, and the condition that led to the development 
of paralysis, epilepsy and idiocy, or possibly all three con- 
ditions combined, was tolerably well understood. One 
small group of these, which included the severest form of 
idiocy, attracted the author's special attention. It ran in 
families, a number of children of the same family being 
affected in the same way. The children appeared to do 
well until about the fifth to eighth month, when a retrogade 
movement would set in. All cerebral functions, motor and 
sensory, became impaired. Child soon became idiotic, 
blind, more or less paretic, and death took place from maras- 
mus. He here exhibited a case in which there was no 



20 NEUROLOGICAL. [Sept., 

spontaneous movement of any sort, child sitting listlessly 
on the nurse's lap. Knee-jerk distinctly exaggerated. No 
ankle clonus. Plantar reflexes increased. Child died at 
the age of twenty months. A week before death there 
appeared considerable fever and several convulsive seizures. 
Brain was firm to touch and almost as hard as a brain that had 
been in Mueller's fluid for several weeks. The pia could 
easily be detached. Marked changes were found in the 
cortex and not a single normal pyramidal cell could be dis- 
covered. The cell-bodies were altered either in shape or in 
general appearance. The cell nuclei and nucleoli were dis- 
tinct enough and were surrounded by the altered cell body, 
which did not properly take the ordinary staining. He 
thought this case could hardly be taken as a distinct form 
of idiocy and of arrested cerebral development. — (New York 
Med. Jour., July 30, 1892.) 

B. M. CAPLES. 



Frequency of Cerebral Tumors. — Seidel reports that 
Bollinger has found 100 cases of brain tumor in 8488 bodies 
dissected in the Munich Pathological Institute in ]4 years, 
being 1 in 85. Hale White found 1 in 59. 27 were tuber- 
cular, 39 sarcomas, gliosarcomas and gliomas, 2 cysticerci, 
1 actimycosis, 3 cholesteatomas, 2 cysts, 2 carcinomas, 2 
psammomas, 6 gummas, and in 16 cases the nature of the 
tumor was not mentioned. Of the 27 tubercular tumors, 
6 were operable perse, although in three of these, other or- 
gans were also infected. Of the remaining cases, one was 
situated in the cerebellum and two in the occipital lobe. 
This gives, as available for operation, 11 per cent, as against 
6 per cent (Starr) and 7 per cent (White). These three 
cases had presented no cerebral symptoms during life. Of 
the 39 sarcomas, gliosarcomas and gliomas, 2 were operable, 
and had been diagnosed a considerable time before death. 
The cases of cysticercus and actinomycosis were of central 
location and not amenable to operation. The two carci- 
nomas were of the size of a filbert and in an accessible 
location, but were metastatic in their nature. Of the cysts, 
one was multiple and the other larger than an entire hemis- 
phere. Of the two psammomas, one was central ; the other 
was found accidentally in the body of a man of 77 years. 
Of the 16 tumors of unspecified nature, one only was 
operable. — (Berlin. Klin. Wochensch., No. 26, 1892.) 

G. J. KAUMHEIMER. 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 21 

Tumor of Optic Thalamus. — Dr. Major gives notes of 
the case of a girl, aged 23, who for months before admission 
to hospital had pains in left temporal region, worse at 
night. Could read perfectly, but noticed that on looking at 
two people she only saw the left one. Two months later 
sought treatment for her sight ; one eye was hemiopic. 
Five weeks later suddenly lost power in right arm, leg and 
side of face. There was some numbness of right side and 
thickness of speech, but no aphasia or loss of consciousness. 
Regained power to a great extent. Three weeks later she 
had a similar attack from which she was recovering on 
admission. Was bright and intelligent. Temperature 
a little raised ; right pupil dilated ; right synonymous 
hemiopia ; paralyzed muscles, flaccid. Diagnosis : tumor of 
posterior part of left optic thalamus pressing upon posterior 
limb of inner capsule. Iodides given. Fever increased and 
delirium commenced; then prolonged stupor and death. 
Post mortem : some meningitis, and left optic thalamus dis- 
tinctly enlarged ; on section, posterior part contained a 
rounded, firm, slightly greenish-colored tumor, which 
pressed upon the posterior portion of the inner capsule. 
Structure was not typical, microscopic examination show- 
ing nests of large ill-defined cells imbedded in a fibrous 
tissue. — (Lancet, April 23, 1892.) 

B. M. CAPLE8. 



A Case of Glioma Teleangiectaticum. — The speci- 
men shown was obtained from the brain of a laborer, aged 
41. He had always been healthy up to about a month be- 
fore death. At that time, during a great effort, he noticed 
a tremor of the left extremities. He then immediately 
lost all power over his limbs and sank to the ground, but 
was fully conscious. On admission to the hospital, almost 
a month later, active motion on the left side was almost 
impossible. Passive motion caused pain and elicited con- 
siderable resistance. There was no disturbance of sensa- 
tion. The patellar reflex, as well as the mechanical and 
galvanic excitability of the muscles on the left side, were 
increased. The left leg, according to the patient, felt colder 
than the right. The only complaint was of headache, 
w T hich became worse. Pulse 48. Sopor, followed by excite- 
ment, set in and death in coma followed on the fourth day 
in hospital. Autopsy revealed a noticeable dryness 
of the membranes, an enlargement of the right hemis- 
phere and flattening of the convolutions on that side ante- 



22 neurological. [Sept., 

riorly. The white substance near the right nucleus cau- 
datus showed a diffuse yellow color. Section of the right 
hemisphere showed a large soft focus, measuring 5 cm. in a 
sagittal and 4 cm. in a transverse direction, consisting 
partly of blood and in part of a soft, glassy, gray tissue. 
The surrounding tissue was stained a diffuse yellow. Micro- 
scopic examination showed the tumor to be a glioma, rich 
in cells, with thin-walled, dilated vessels, fresh blood clots, 
some brown pigment and occasional granular cells. The 
author attributes the first rupture to the sudden exertion. 
A tumor of the brain was suspected during life. — (Dr. A. 
Kruse, Deutsche Med. Wochenschr., No. 28, 1892.) 

G. J. KAUMHEIMER. 

Cerebral Cysticercus. — Dr. Matignon reports (Jour, de 
Med. de Bordeaux, July 12, 1892) the case of a female 
found in the street aphasic and in collapse. On admission 
to an hospital she had generalized convulsions lasting from 
three-quarters of an hour to an hour. The following day right 
hemiplegia with aphasia and relaxation of the anal sphincter 
was evident. The heart was normal. Two days later the 
patient died. The lateral ventricles were free from lesion. 
On the left third frontal convolution a taenia cyst was 
found ; on the anterior extremity of the left first frontal 
convolution another, and on the inferior face of the cere- 
bellum a third. The right sphenoidal lobe contained a 
walnut-sized cyst with cartilaginous walls ; clearly a degen- 
erated taenia cyst. 

J. G. KIERNAN. 



Pituitary-body Tumor. — Dr. Christian (Ann. Medico- 
Psych., July-Aug., 1892) reports a case in which a melan- 
choliac developed vivid visual hallucinations which per- 
sisted during five years of Dr. Christian's care. He became 
completely paretic. On autopsy a chicken-egg-sized tumor 
was found to fill the sella turcica and strongly imbedded in 
the cerebral substance, from which it was, however, distinct. 
This pediculated tumor, adhering strongly to the sella turcica, 
had prolongations flattening the optic nerves. The optic fibers 
up to the corpora quadrigemina were diminished. The 
chiasm was compressed by the tumor which had developed 
in the pituitary body and preserved a lobulated appearance 
similar to it. The anterior portion had creased deeply 
into the base of the encephalon. It was symmetrical in 
development and weighed twenty grams. It contained 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 23 

trembling pulpy mass limited by fine connective tissue 
fibers. In the front of this pulp was a hemorrhagic patch 
due to vessel rupture. 

J. G. KIERNAN. 



Abscess of the Brain. — Dr. Hartmann demonstrated 
an interesting case of brain abscess before the Congress of 
the German Surgical Society, held at Berlin, June 8. The 
patient had fallen from his horse in the last French war. 
After several years he began to suffer from headache which 
gradually became serious. Was sent from one physician to 
another without relief. After opening and cleaning out of 
the abscess he was permanently cured. — (Med. Record, July 
16, 1892.) 



B. M. CAPLES. 



Abscess of the Left Frontal Lobe. Gouget reports 
the case of a man, aged 54, who, while in his usual state 
of health, suddenly lost consciousness. Recovery was rapid 
and complete so that he was able to resume work. Shortly 
afterward he again became suddenly unconscious, this time 
remaining so. Taken to hospital and found to be coma- 
tose, and to have complete right hemiplegia with conjugate 
deviation of head and eyes. Under influence of repeated 
injections of ether recovered sufficiently to recognize 
parents and respond to questions by signs, but quickly be- 
came comatose again. Died four days after admission. At 
necropsy a circumscribed abscess was found in second left 
frontal gyrus; from this between three and four "spoonfuls" of 
very thick pus were evacuated. The anterior wall of the 
abscess cavity was situated about two centimeters behind 
the anterior boundary of the frontal lobe ; "posteriorly and 
below", the limit corresponded with the anterior extremity 
of the corpus striatum which was slightly infiltrated with 
pus. Owing to absence of diagnostic signs surgical inter- 
ference was impossible ; this Gouget regards as unfortunate, 
since it offered every prospect of success. — (Brit. Med. Jour., 
July 9, 1892.) 

B. M. CAPLES. 

Focal Lesions In the Medulla. — Dr. Leo Chassel 
discusses this subject in connection with four cases. Case I 
was a boy of 11, who developed an osteomyelitis of the left 
tibia after a slight traumatism. 17 days after the injury, 
and 11 days after the first abscess was opened, clonic spasm 
of the left lower extremity was observed. The next morn- 



24 neurological. [Sept., 

ing he said his neck was stiff and that swallowing was dif- 
ficult. The head was constantly turned to the left. P. 120, 
small, soft and dicrotic; R. 20, costo-abdominal in type. 
Speech was not involved ; the uvula was slightly deflected 
to the left. Patient said the nucha was sensitive to touch. 
Motility intact; periosteal reflexes absent; patellar reflex 
increased ; some indication of knee and ankle clonus ; some 
hyperalgesia over the entire body. The clonic spasm con- 
tinued to recur 2 or 3 times a day. The other symptoms 
remained the same until death on the ninth day after the ap- 
pearance of cerebral symptoms. The cerebral changes found 
on autopsy were : A slight quantity of cloudy serum in the 
lateral ventricles; the substance of the outer part of the 
pyramid and the inner and lower portion of the olivary 
body on the right side were completely softened and of a 
reddish gray color; the lower part of the right pyramid was 
filled with miliary haemorrhages. On the left side of the 
lumbar enlargement, at the level of the lumbar roots, a small 
quantity of a fibrinous exudate was found. Chassel counts 
this as an abscess of the medulla. In this he follows the ex- 
ample of Erb. He assumes, however, a very unusual mode of 
infection and points out that the usual theory of embolism 
would hardly explain this case. It would certainly be very 
unusual to find, in a case of pyaemia like this one, a single 
embolus in the brain and not one in the internal viscera. 
In this case the author believes that at least the inflamma- 
tory lesion, if not the infection, traveled up the nerve trunks 
to the cord. The limited lumbar meningitis would support 
this view. Its path within the cord he could not determine, 
as no examination was made. A similar route is assumed, 
without objection, in cerebral abscess following suppurative 
otitis. Case II. Male, aged 50. Two weeks before, the left 
side had become paralyzed. There had been no loss of con- 
sciousness, but severe vertigo, headache and vomiting. On 
admission the right oral angle was drooping and the facial 
folds on that side obliterated; the pupils reacted to light, 
the eyes could not be moved laterally, but could be moved 
somewhat upward and downward. There was rotatory nys- 
tagmus of the right eye and bilateral ptosis, more marked 
on the left side. Patient could read large print. The mobil- 
ity of the left upper extremity was reduced, sensation being 
normal. Both motion and sensation were reduced in the 
left lower extremity, but patellar reflex was normal. Patient 
died after 5 days stay in hospital of pneumonia. Autopsy 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 25 

showed a serous infiltration of the meninges of the convex- 
ity. The ependyma of the ventricles was thickened. The 
region of the right olive and pyramid was swollen. On 
opening the fourth ventricle a semi-globular tumor was seen 
reaching from the locus caeruleus to the striae acusticae, 
which were pushed backward, and involving the right side 
more than the left. The width of the tumor was 3 cm., its 
length 2 cm. and thickness 1 cm. On section it was seen to 
be due to a recent haemorrhage which extended into the 
pons and medulla. The vertebral arteries were atheroma- 
tous. Case II T was a male, aged 32. *This patient 
noticed a difficulty in swallowing, and twitching of the right 
arm and leg. The next morning, when he awoke, he found 
that he was paralyzed on the right side. When first seen, 
12 days later, the right side was weaker and clumsier than 
its fellow, there was vertigo on standing and a suggestion of 
knee clonus. Touch and pain sense were much reduced in the 
right leg, less so in right arm. The progress of the case was 
as follows: 27th day: speech, deglutition and mastication 
have become more diflicult. There is some regurgitation of 
fluids. 32nd day: walking more difficult, complains of 
dizziness, headache and bilious vomiting. 47th day: 
tearing pain in right hand. Right arm and right knee 
are stiff. Bilateral ankle clonus and severe vertigo. 48th 
day: speech has become more and more nasal, uvula de- 
flected to the right, the palatal arch was lifted somewhat on 
phonation, not on touch. Facial nerves intact. 51st day: 
on turning the head to left, an attack of dyspnoea occurred. 
Slight ptosis on left side, sense of taste much reduced and un- 
certain. 62nd day: rectal incontinence, slight paralysis of 
left abducens. Tongue can only be protruded 1 to 1 J cm. 
69th day: constant twitchings in right arm, so that patient 
lay on it to stop them. He states that any attempt to turn 
to the left causes vertigo and vomiting. Breathing is im- 
peded. 72nd day: biting is difficult. The left side of face 
is paretic. 79th day: speech unintelligible; incontinence of 
urine. 91st day: on raising the patient, fainting and spasm 
of glottis occur. 101st day: eyes turned to right and 
fixed. Death on 128th day from pulmonary oedema. Autopsy 
showed the pons to be about one-third larger than normal. 
Its substance, excepting the superficial portion of its anterior 
half, was changed into a reddish-gray very vascular tissue, 

*This ease has already been published by Mader, Jahresb. d. Rudolf- 
Stiftung, 1886. 



26 neurological. [Sept., 

gelatinous in spots, and interspersed with foci of dry cheesy 
material varying in size from a hempseed to a pea. This 
change extends about 1 cm. into the medulla, but only in its 
central part. Case IV was a woman, aged 57, who com- 
plained of vomiting, vertigo and weakness of sight for six 
weeks. The vertigo disappeared in the recumbent position. 
Vomiting followed upon motion. Examination revealed rigid 
peripheral arteries. On turning the eyes to the extreme left, 
the left eye halted a little and then after a few twitching 
movements passed back to the median position. There was 
a slight paresis on the left side of the face. In sitting, the 
patient leaned to the left. In walking, there was a tendency 
to fall to the left, even with the eyes closed. Later, the head 
was turned rigidly to the left. Death after an illness of 
about eight weeks. Autopsy showed the pia at the base to be 
covered w^th tubercles, varying in size from a mustard to a 
.hempseed. In the left lateral recess of the 4th ventricle a 
cheesy nodule larger than a pea was found. This projected 
into the ventricle a little and was covered by a thin layer of 
reddish tissue. Another nodule as large as a hempseed lay 
between this and the raphe, about 2 mm. distant from the 
latter. The stride acustica3 could not be seen on the left 
side and were indistinct on the right. The diagnosis of 
lesions of the medulla is very difficult, in fact, unless nuclear 
lesions can be demonstrated, almost impossible. The facts 
that the medulla is crowded with important systems of nerve 
fibers, that lesions of slight extent may cause varying, if not 
conflicting symptoms, that some cases of bulbar lesion may 
cause only peripheral paralyses, or even no symptoms, all tend 
to obscure the clinical picture. Besides this, our knowledge of 
medullary reflexes, and even functions, is limited. Owing to 
the short and direct course of the bulbar nerves we cannot 
differentiate between a lesion at their origin and in their 
course within the skull. Glycosuria has never been observed 
in lesions of the medulla in man, although the piqure is in- 
variably successful in producing it in animals. Cases II and 
IV presented no bulbar symptoms whatever. Chassel then 
attempts to harmonize various symptoms observed in these 
cases. The turning of the head to the left (case I), the ro- 
tatory nystagmus (case TI), the vertigo and turning of face 
and eyes to the right (-case III), and the similar symptoms 
incase IV, he considers as disturbances of co-ordination and 
forced positions. Bechterew has shown that forced move- 
ments and positions result from unilateral lesions of the 



1892.] PATHOLOGY AND SYMPTOM ATOfcO 27 

olives, the posterior cerebellar peduncles, the acoustic nuclei 
and the upper layers of the cerebral peduncles, and that they 
disappear upon the infliction of a Bymmetrical lesion. The 
author assumes thai our relations with surrounding space 
are regulated by the consensual action of the eye, the ear and 
the muscular sense. He also assumes the existence in the 
medulla of subcortical centres in reciprocal relation with all 
these points. Tin- paths of these relations he places in the 
fillet. If by a lesion of the medulla these centres be affected, 
certain peculiar motions and positions are called Forth, which 
are commonly called "forced. The author believes these to 
be pathognomic of bulbar lesions. — I Wien. Med. Wochenschr^ 
Nov. 9-13, L892. 

O. J- KAUn iiia.Mi.K'. 



Local An.i:-tiii>i a AS a QuTDH in THE DIAGNOSIS OF 

Lesions of the Lower Spinal Cord. Dr. M. Allen Starr 
writes an elaborate and interesting article upon this subject. 
It is one that is very difficult to abstract, for it should be 

read in detail and in connection with the illustrations that 

accompany it. We abstract the following: "The distribu- 
tion of anaesthesia in lesions of the lower part of the Bpinal 

cord is divided into /.ones. 1. The first zoru is oval in 

shape, small in extent, and includes the perineum, the pos- 
terior part ot the scrotum in males, the vagina in females; 
it also includes the mucous memhrane of the rectum. 2. 
The second zone is heart-shaped — point up — and includes 
the entire scrotum and posterior surface of the penis and 
mucous memhrane of the uretha in males — the entire 
genitals of the female, except the outer surface of the labia 
majora and the mons veneris. 3. The third zone is consid- 
erably larger, involving a greater surface of the buttocks 
and extending down the back of the thighs over a trian- 
gular area, point down. This has been named the "saddle- 
shaped area," coinciding about with the surface of the seat 
in contact with the saddle when riding. A zone of anaesthe- 
sia of this shape is due, as the autopsy in Oppenheim's case 
shows, to a lesion involving the fifth, fourth and third sacral 
segments. 4. The fourth zone is of a similar shape to the 
third, but more extensive, a greater surface on the back of 
the thighs being involved, and the anaesthesia extends in a 
band almost as low as the popliteal space. This area has 
been established clinically in several cases : there is, as yet, 
no autopsy to determine its lesion ; but since the smaller 



28 neurological. [Sept., 

zone is due to lesion at the third sacral segment, and the 
next larger zone is due to lesion in the fifth lumbar seg- 
ment, it is allowable to conclude that this region corres- 
ponds with the second and first sacral segments. In thus 
outlining four zones of the skin and assigning them to 
various segments of the sacral portion of the spinal cord, 
it is not my intention to lay down artificial boundaries or 
to affirm that all cases will exactly coincide. The lesions in 
the sacral cord are not limited exactly to one or two seg- 
ments. The sacral cord is small in extent and lesions in- 
volve it to a greater or lesser degree, consequently these 
zones are not always symmetrical on the two sides of the 
body ; the lesion being a little higher on one side of the 
cord than on the other, the zone of anaesthesia will be 
greater on one thigh than on the other, as in my first, fifth 
and sixth cases, and in those of Herter, Mills and Osier. 
I only wish to show that as the cord is invaded by disease 
from below upward, the area of the skin which becomes 
anaesthetic increases in extent, and that the shape of the 
area is characteristic ; so that from the study of the area 
the extent of the lesion can be determined. 5. The fifth 
zone of anaesthesia is seen to include the first four zones and 
to extend down the back of the thigh through the popliteal 
space in a band, and then to descend the outer surface of 
the leg to the foot. In some cases it ends at the ankle, in 
others it involves the entire side of the foot, dorsum and 
sole, and three and a half toes. Eulenberg's case, cases of 
Kahler and Mills not cited here, and my second and fifth 
cases demonstrate this distribution. When a lesion extends 
from the sacral into the lumbar cord the anaesthesia ex- 
tends from the thigh down the outer side of the leg. This 
area then corresponds to the fifth lumbar segment of the 
cord. 6. The sixth zone of anaesthesia is produced by a 
lesion of the third lumbar segment. When the third lum- 
bar segment is diseased, the entire back of the thighs and 
legs is anaasthetic, and the front of thighs is also anaesthetic, 
except over a funnel-shaped zone which extends from 
above downward, the narrow tube of the funnel 
reaching along the shin even to the foot. This zone 
will probably be separated later into two separate 
parts corresponding to lesions of the fourth and third lum- 
bar segments. There is not as yet a sufficient number of 
cases to warrant such a distinction. The exact limits of 
anaesthesia on the feet are still uncertain, and no more 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 29 

exact statement than that given is warranted. It is quite 
common to find the inner arch of the foot sensitive when 
the toes and heel and entire dorsum are anaesthetic, and it is 
probable that the higher the lesion the greater the anaes- 
thesia on the foot. 7. The last and largest zone of anaes- 
thesia is produced by a lesion of the four lower 
lumbar segments, that is, by destruction of all but 
the first lumbar segment of the cord. It will be 
noticed that the line of anaesthesia is much lower in front 
than behind, and that it follows the line of Poupart's liga- 
ment. It is only when the first lumbar segment of the 
cord is invaded that the abdominal wall becomes anaesthetic. 
From this level upw 7 ard, the zone of anaesthesia extends 
around the body in a girdle, and there is no difficulty in 
locating the level of the lesion in the dorsal cord. It is to 
be remembered that in all these lesions and areas of anaes- 
thesia, the anus, perineum and the genitals are included in the 
insensitive region. This is an important fact in the differen- 
tiation of cases of organic from junctional paraplegia. It is 
also to be noticed that the shape of the area of anaesthesia 
in the back differs in organic and in functional cases. — (Am. 
Jour. Med. Sciences. ) 



Concussion of the Spinal Cord. Dr. MacDougall re- 
ports the case of a man who fell backward from a moving 
railroad train. There was no loss of consciousness. Legs 
absolutely paralyzed ; sensation was distinctly impaired ; 
bladder paralyzed ; bowels constipated ; temperature sub- 
normal ; pulse feeble. Two days later there was no evi- 
dence of improvement in motility but sensation returned 
somewhat rapidly. Third day could move ankles and toes 
and could very feebly and slowly draw up his legs. Bladder 
began to regain its expulsive power. At the end of a week 
could move his limbs freely ; use of catheter no longer 
necessary; sensation fully re-established; temperature 
normal. After three weeks was allowed out of bed. Could 
stand firmly, but power of walking was feeble and unsteady. 
Six weeks after accident, with aid of stick could move 
about with comparative freedom. About a year after ac- 
cident author examined him and found him in perfect 
health, patient stating that he w r as as vigorous as in his 
earlier days. — (Lancet, July 16, 1892.) 



B. M. CAPLES. 



30 neurological. [Sept., 

The Reflexes in Spinal Injuries. From an analysis 
of twenty-nine cases of injuries to the cervical and dorsal 
regions of the spinal cord under his observation, Thorburn 
concludes that in total transverse lesions of the spinal cord, 
both superficial and deep reflexes below the functional level 
of injury are permanently and entirely abolished, while in 
partial lesions the reflexes are retained, perhaps exag- 
gerated. It is thought that abolition of reflexes is depend- 
ent upon isolation of spinal centres from their cerebral 
connections. It is further concluded that shock is not the 
cause of early loss of reflexes in spinal injuries. If the 
lesion causes complete paralysis and anaesthesia, deep re- 
flexes are always lost. If motility or sensibility, or both, 
return, reflexes likewise reappear. The rectum and bladder 
participate in the derangement of reflexes. — (Med. News, 
July 23.) 

B. M. CAPLES. 



A New Symptom Indicating Combined Cerebellar and 
Spinal Inco-ordination. Dr. Spitzka reported a case be- 
fore the American Neurological Association, of a child whose 
attitude and appearance were characteristic of that form of 
pseudo-hypertrophic paralysis in which the atrophy of the 
arms markedly antedated wasting in the lower extremities. 
Whether dressed or undressed, under examination and 
observation or not, patient had a habit with his right hand 
thumb and fingers flexed (fingers but slightly so) of mak- 
ing a sudden motion toward the nose, while at the same 
time there was a straightening out in his attitude, and stiffen- 
ing of the muscles involved in maintaining the erect post- 
ure were associated in the act. A peculiar expression would 
cross his face, head and eyes being turned toward the ap- 
proaching fingers. The child had certain imperative con- 
ceptions, such as the fear of going under a certain tree ; 
terror of a Newfoundland dog at later hours of the day, for 
which at other times he showed great affection ; fear 
of the stairs, and even on the level floor of the house he 
had an impression as of a yawning precipice. Three mem- 
bers of father's family were insane. The child had pro- 
gressed as these cases usually do, had developed a 
marked grade of imperative conceptions and morbid fears 
and a slight degree of imbecility. — (Med. Record, July 30, 
1892.) 

B. M. CAPLES. 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 31 

Heterotopia of the Spinal Cord. Dr. Ira Van Gieson 
read a paper on the subject of bruises of the cord as 
related to the cases of so-called heterotopia, or congenital 
malformation of the cord substance, before a meeting of 
the New York Neurological Association on June 7. After 
very careful study of the literature of all the available 
microscopic specimens, and after experimental work, the 
speaker has been forced to the conclusion that most of the 
malformations of the cord that had previously been pub- 
lished were really cases in which the cord had been injured 
in the removal and in the process of hardening. The fact 
that microscopic examination of cords accidentally or experi- 
mentally injured showed the same distortion of displacement 
of the constitutent parts as the specimens exhibited as cases 
of congenital malformation, had led, atonce, to doubt of their 
having been cases of true heterotopia of the cord. The 
speaker said that it was very easy to mistake such distortion 
for malformation when the cord did not show any gross 
injury. It took very slight pressure on a cord in a recent 
state to cause separation of its structures. The evidence of 
such injury would show itself in the section by a displace- 
ment of some of the white or gray matter to the higher 
and lower level, or by one or more of the horns being 
crowded to one side or the other, or being almost, or quite, 
obliterated. The proof of such an injury being the cause 
of displacement was, that in making further sections the 
absent or distorted portions would be found in different 
situations. The author illustrated the subject by a large 
number of lantern slides, the specimens having been taken 
from his own and other observers' work. In the course of 
his remarks he referred to the specimens that were labelled 
"malformations of the cord in cases of acute myelitis". He 
did not see how it was, that the fact of the extreme soften- 
ing of the cord which always took place in this disease had 
been overlooked, making it almost impossible to handle the 
cord without inflicting injury, so that sections in such cas-as 
would be sure to show distortion of some of its elements. 
Very careful analysis of these cases pointed clearly to their 
being post mortem injuries and not congenital malforma- 
tions of the cord. Some of the specimens showed how 
pinching, bruising or doubling of the cord produced the 
abnormal conditions, such as enlargements or small nodules, 
which were frequently seen, and, microscopically, how 
masses of gray matter might be found in the white sub- 



32 neurological. [Sept., 

stance, the gray horns attenuated, enlarged, distorted or 
absent in part, or wholly, the presence of three or more 
horns, and also why the fibers were sometimes found taking 
abnormal directions. From his very thorough study of 
the subject the author has been forced to the belief that, 
if he could produce experimentally conditions identical 
with those that had previously been described as congeni- 
tal malformations, he was very much in doubt as to their 
being genuine. And also the fact that such abnormal con- 
ditions of the cord had not produced any corresponding 
symptoms in itself, militated very much against the diagnosis 
of cord disease. The author says the mallet and chisel are 
to be avoided, as the blow or jar upon the cord is a fruitful 
source of injury, and also that if the chisel is forced 
against the cord, while it has resilience enough to spring 
back and not show the pressure, it may show it microscopic- 
ally, hence these instruments should not be used. The 
author always employs a saw and scissors, and in harden- 
ing the cord it should be suspended in a tube. — (New York 
Med. Jour., July 16, 1892.) 

B. M. CAPbES. 



The Relations op Senile Cerebral Atrophy to 
Aphasia. — The focal symptoms of paretic dementia, among 
them aphasia, are seldom due to appreciable focal lesions. 
The general opinion is that the aphasia of senile cerebral 
atrophy, except the amnesic form, is always due to a coarse 
focal lesion. Pick reports a case of senile atrophy present- 
ing symptoms like those of Wernicke's "transcortical sensory 
aphasia," namely : loss of understanding of vocal and 
written speech, paraphasia and partial loss of the ability to 
repeat spoken words, in which autopsy showed an atrophic 
brain weighing without the membranes 1150 gms. The 
right hemisphere weighed 500 gms.; the left 470 gms. All 
gyri were small, especially those on the left side, the atrophy 
being especially pronounced in the left temporal lobe. No 
coarse lesion could be detected. Pick quotes a case from 
Bevan Lewis, which presented amnesic and atactic aphasia, 
with great atrophy of the left frontal and parietal lobes and 
less pronounced atrophy over the rest of the brain. 
Skwortzoff reports a similar case of simple cerebral atrophy, 
from Magnan's practice. -{Prag. Med. Wochensch., No. 16, 1892.) 



G. J. KAUMHEIMER. 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 33 

Multiple Vision. Venturi (session of the Italian Fre- 
niatrical Society, Archivio Italiano, 1891) reported a case of 
an individual belonging to a family with strong neurotic 
tendencies, who presented certain peculiar symptoms. One 
was a peculiar intolerance of the quinine salts, the use of 
which was followed within a few hours by pruritus, bullae 
and swelling lasting twenty-four hours, and producing 
a pronounced and troublesome balanitis. The other was 
that the patient was subject to sudden nervous attacks, dur- 
ing which all the objects that came into his view were mul- 
tiplied forty or fifty fold, varying according to their size and 
the extent of the visual field. During this, consciousness 
was perfect, and the individual realized that the phenome- 
non was only a subjective one. The author was inclined to 
interpret this phenomenon not as of cortical but rather as 
of peripheral origin, due to some spasmodic action of the 
accommodation muscles. In the discussion Tamburini 
held that it could also be explained by assuming it the re- 
sult of some special vibratory movement (due to the nervous 
attack) of the perceptive cells in the cortical visual centres, 
so that there was either a lack of fusion of the contempo- 
raneous images, which thus remained separately presented 
to consciousness, or a so rapid appearance of the different 
successive images that they appeared to the consciousness 
as simultaneous. 

H. M. BANNISTER. 



Case of Toxic Central Amblyopia, Terminating in 
Progressive Atrophy. — Patient excessive drinker and 
smoker. For two years has suffered from dragging pains in 
various parts of body, for relief of which he drank alcohol 
and applied it externally. Pain in head which is worse at 
night and after drinking. Tenderness of large nerve trunks. 
During past six months vision has failed progressively. 
Direct and consentaneous pupil reflexes torpid; accommoda- 
tion reflex more active. Sight impaired in centre of visual 
field. Scotoma symmetrical in each field, and oval .Out- 
side of central amblyopic region visual field more nearly 
normal, except at periphery. Right field, is peripherally 
contracted at upper and nasal limit. Left field is contracted 
somewhat at its nasal boundary. Color perceptibly im- 
paired. Diagnosis of central amblyopia dependent upon a 
toxaemia due to tobacco and alcohol. The case is one of 
obtacco-amblyopia with the added factor of a progressive 



34 neurological. [Sept., 

atrophy, as shown by extensive involvement of color sense 
and commencing limitation of visual fields, together with a 
peripheral alcoholic neuritis that preceded the eye symp- 
toms and continued with them. Dr. Hutchinson observed 
that strong tobacco was the controlling drug in these cases 
in England, whereas in Germany, Uhthoff found that 
alcohol played a greater etiological part in the production 
of amblyopia. The etiological indication is our guide to 
treatment of central amblyopia and applies to all forms 
of toxaemic neuritis. Stop entirely the introduction of both 
poisons — alcohol and nicotine — into the system. Restore 
the normal nervous tone by a carefully regulated life, good 
hygiene, fresh air, tonics, and a nutritious and easily 
digestible diet. Iodide of potassium is a useful drug in 
these cases, especially where active ocular symptoms are 
present. Gentle galvanization of the eyes and extremities 
is followed by good results. — (Med. Record, July 16, 1892.) 



B. M. CAPLES. 



A Case of Congenital Facial Paralysis. (SckuUze, 
Neurologisches Centralblait, No. 14, 1892.) Facial paralysis, 
except when the result of some injury during labor, is ex- 
ceedingly rare, and up to the present time no cases have 
been reported. Mobius says that this condition has only 
been observed in connection with paralysis of the muscles 
of the eye, although he does not deny that it may occur 
alone. Schultze reports a case in which the only suspicion 
of complication of the oculo-motor nerve is a slight dilata- 
tion of the pupil on the affected side. The patient, a girl 
four years old, is of healthy parentage. Labor was normal 
and the paralysis was noticed immediately after birth. Upon 
examination the child presents the typical symptoms of left 
facial palsy with slight dilatation of the left pupil. Elec- 
trical reaction is absent. The cause, as well as the seat of 
the disease, is uncertain. The first thought that suggests 
itself is imperfect development of the facial nucleus, but 
a peripheral lesion cannot be excluded. 



JOS. KAHN. 



Bilateral Accessory Paralysis in Syringomyelia. Dr. 
A. Schmidt reports a case of syringomyelia, probably of 
the cervical cord. There was bilateral atrophy of the mus- 
cles of shoulders and arms, with analgesia and ther- 
msesthesia with intact tactile sensation, between the level of 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 35 

the angle of the lower jaw above and the fourth costal in- 
terspace below, and in both arms. Rotatory nystagmus was 
present, but besides this the cranial nerves were not in- 
volved, with the exception of the accessory. Laryngoscopic 
examination showed complete paralysis of the left vocal 
cord, which was atrophied and in the cadaveric position. 
As the right vocal cord crossed the middle line in phona- 
tion, but moved only very slightly during respiration, a 
paresis of the crico-arytenoideus posterior was undoubtedly 
present. No disturbance of sensation in the larynx, or diffi- 
culty in swallowing. From the extent of the symptoms, the 
lesion in the cord would seem to be limited to the section 
between the fourth and eighth cervical nerves. The atro- 
phy of the trapezius and sterno-mastoid muscles, and the 
laryngeal symptoms, must be referred to a nuclear lesion of 
the spinal accessory nerve. It is noteworthy, that while the 
entire extensive nuclear origin of this nerve seemed to be 
included in the pathological process, neither of the neighbor- 
ing nuclei (vagus and hypoglossus) were affected in the 
least. The author assumes that prolongations of the de- 
generations extended from the main body of the disease in 
such a direction as to affect the accessory nuclei. It was 
evident, however, that some of the cells were functionally 
intact, as all the motor fibers of the vagus are derived from 
the spinal accessory, and there was no dysphagia. Schmidt 
then discusses a number of reported cases of lesion of the 
spinal accessory nerve and classifies the symptoms as follows: 
1. Lesion external to the ganglion of the vagus, usually uni- 
lateral and restricted to the external (spinal) branch. As a 
result, paralysis, more or less complete, of trapezius and 
sterno-mastoid muscles. Lesion of the internal (vagus) 
branch is always accompanied by sensory disturbances on 
the part of the vagus. 2. Lesion at the base, between jug- 
ular foramen and foramen magnum, usually unilateral. 
Both branches involved. Omission-symptoms of external 
branch as in 1; of internal branch complete; unilateral 
paralysis of velum palati, pharynx and all laryngeal mus- 
cles, possibly rapid pulse. 3. Lesion situated in the verte- 
bral canal at the origin or in the cord; frequently bilateral. 
Both branches involved, symptoms on part of internal 
branch usually incomplete; of external branch, as in 1. — (Dr. 
A. Schmidt, Deutsche. Med. Wochensch., No. 26, 1892.) 

G. K. KAUMHEIMER. 



36 neukological. [Sept., 

Syphilitic Spinal Paralysis. — Erb has for several 
years noticed in subjects of syphilis certain forms of 
spinal disease, which in his opinion present so many pe- 
culiar characteristics that thev constitute a well marked 
clinical variety. According to his paper (Neurol Gentralblt., 
No. 6, 1892) disturbances of mobility, and later, severe 
spastic paresis, developing slowly in the course of months, or 
even years, are the chief peculiarities. True paraplegia is 
rare. The gait is exquisitely spastic, although muscular 
tension and contractures are slight. The patellar reflex is 
always increased. Disturbances of sensation are generally 
very slight and often quite difficult to demonstrate. Vesi- 
cal insufficiency and diminution of sexual power are almost 
always present ; muscular atrophy is generally absent. The 
electric irritability is normal. The upper extremities are 
never involved. The course of the trouble shows an un- 
mistakable tendency toward amelioration. This is espe- 
cially the case after energetic specific treatment. The clini- 
cal picture is so characteristic that Erb has repeatedly 
made the diagnosis of specific infection before obtaining 
the patient's history on this point. The differential diag- 
nosis from the other chronic diseases of the cord, espe- 
cially from tabes, multiple sclerosis, compression and 
syringomyelia, is easy. It can be distinguished from spastic 
spinal paralysis by the constant presence of sensory and 
vesical disturbance, and by the remarkably slight muscular 
tension, as well as by the history and course. The diag- 
nosis from dorsal transverse myelitis is more difficult. Here 
the incompleteness of the paraplegia, if it occurs, and the 
tendency to recovery, as well as the slight muscular tension 
and slight sensory disturbances are to be noted. 
Its diagnosis from other syphilitic affections of the 
brain and cord, and from specific peripheral neuritis 
should not .be difficult. Its relation to syphilis is estab- 
lished, not only by the fact that all the subjects 
were syphilitic, but that other etiological factors were 
absent and that all the cases were found to have occurred 
from three to six years after infection. This trouble seems 
to be much rarer than tabes. Erb refers the seat of the lesion 
to the posterior portions of the lateral columns of the 
dorsal cord, later extending to the posterior columns and 
posterior cornua. Its nature he believes to be partly infil- 
trative, partly degenerative. He thinks he has established 
its claims as a clinical entity, at least until further investi- 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 37 

gation, and suggests the name which furnishes the title of 
this article.— ( Wien. Med. Presse, No. 16, 1892.) 

G. J. KAUMHEIMEB. 

A Case Presenting the Symptoms of Landry's Para- 
lysis, with Recovery. — Dr. Miles reports a case in the 
Medical News of July 9, entitled as above. Patient thirty- 
three years of age. Temperate in habits and had been in 
good health previously to attack described. On Nov. 26 
oaught a severe cold. Nov. 28 was wet by rain. Then 
experienced intermittent pain in calf of leg. About Dec. 1 
he observed "a cold feeling across his toes as if he had 
dipped them in cold water". Same feeling attacked left 
upper lip as if it were chapped and air blew upon it. These 
feelings continued till Dec. 6. In afternoon of that day 
attempted to go up stairs and found he "did not have the 
power to raise the left leg from one step to the other with- 
out serious exertion in the way of dragging it". In a few 
days was confined to his bed, being unable to walk. Feel- 
ings of coldness and numbness continued to get worse and 
to extend upward on his legs to the knees, and also invaded 
the hands and arms to elbows, muscular power steadily 
failing from lower extremities upward. Dec. 17 lower limbs 
completely paralyzed. Muscles of trunk and belly greatly 
weakened. Could not sit up or turn on his side. He 
coughed, but with very little force. Hands and arms quite 
weak with tendency to assume the position of wrist-drop. 
Sensation apparently normal except that sensation of tickling 
on sole of foot was .nearly or quite lost. Reflexes, both 
superficial and deep, were completely lost. No pain on 
pressing the muscles. Muscles responded normally to the 
faradic current, and to galvanic also responded normally, 
contracting quickly without a sign of degenerative action. 
Also contracted from nerve stimulation. Sphincters were in- 
tact. For three or four days the paralysis increased in the 
upper extremities until the patient could no longer use his 
hands. Abdominal muscles became so weak he could not 
cough. Facial nerves became involved in all their branches, 
more decidedly on left side. Patient could not frown; could 
not close left eye; could with effort barely approximate the 
lids of the right so as to make them touch; could not whistle. 
Articulation was somewhat defective from weakness of the 
labial muscles; tongue was unaffected; patient stated 
that it felt thick. Said he felt as if he were being smothered 



38 NEUROLOGICAL. [Sept., 

by his own weight. Breathing became oppressed and he 
had several attacks of threatened suffocation. (Heart-ac- 
tion was not affected either in frequency or force.) At this 
point the progress of the disease seemed to be arrested, then 
improvement, especially of the respiratory symptoms, began 
and proceeded somewhat rapidly, face and arms recovering 
first. The 1st of January could raise himself in bed. On 
the 7th sat up on the side of bed. Next day dressed him- 
self. On the 13th was able to walk alone. On the 20th was 
able to leave the house. A month later limbs were still a 
little weak and patellar reflexes still absent. The author 
thinks this case worthy of record because of the very close 
resemblance of its symptoms to those of Landry's paralysis, 
and does not see why it should not be considered as a case 
of that disease. It is noticeable that the symptom of op- 
pression and difficulty in breathing that usually closes the 
scene in fatal cases of Landry's paralysis was prominent, 
and appeared to lack but little in severity to have caused 
death. 

* B. M. CAPLES. 

Infantile Paralyses Occurring During and After 
Infectious Diseases. — Dr. M. Imogene Bassette publishes 
an interesting article with this title, giving the histories of 
eighteen cases. The author states that any of these forms 
of paralysis may be classed as toxsemic. In a large propor- 
tion of cases the pathological process cannot be called in- 
flammatory; of the spinal cases there may be poliomyelitis 
or diffused myelitis ; other cases may be due to multiple 
neuritis, or to the association of these with central disease. 
She reviews the infantile paralyses following scarlet fever, 
small pox, diphtheria, whooping cough, mumps, malaria in 
children and typhoid fever, and calls attention to the fact 
that hysterical paralysis may be developed after infectious 
diseases, and that it is important to be able to distinguish 
this from organic paralysis. In regard to prognosis, the 
cases of embolism, thrombosis or central hemorrhage will 
be permanent ; cases due to encephalitis may be improved ; 
cases due to uncomplicated neuritis are usually hopeful. — 
[Jour. Nervous and Mental Dis.,) July, 1892. 



The Character of Diphtheritic Paralysis. — In eight 
autopsies upon children that had died from diphtheria com- 
plicated by paralysis, Arnheim found hyperemia and capil- 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 39 

lary hemorrhages in the medulla, inflammatory processes 
in the muscles, and interstitial and parenchymatous degener- 
ation of the nerve fibers. A. believes diphtheritic paralysis 
to be due to parenchymatous neuritis. — (New York Med. Jour., 
July 23, 1892.) 

B. M. CAPLES. 



Combination of Paralysis Agitans and Locomotor 
Ataxia. — Placzek reports a case of this unique combination 
in a male, aged 52, who had had syphilis. The tabetic 
symptoms present were: reflex immobility of pupils, loss of 
teeth, impotence, lancinating pains, pronounced Romberg 
symptom, urinary incontinence and loss of patellar reflexes. 
'Ataxia and disturbances of sensation were absent. The 
symptoms of paralysis agitans were also pronounced. The 
face was rigid, the bodily posture characteristic, tremor pro- 
nounced, slight propulsion but stronger retropulsion present. 
The tabetic symptoms began three years before the paraly- 
sis. P. has been able to find but one doubtful case, by 
Heimann, in literature. The author concludes that if the 
paralysis be due to organic lesions they do not involve the 
parts included in the tabetic trouble. — (Berl. Klin. Woch- 
enschr., No. 14, 1892.) 



G. J. KAUMBEIMER. 



Paretic Dementia and Locomotor Ataxia. — Dr. Joff- 
roy says that while it is (Mercredi Med., May 25, 1892) 
generally admitted that the lesion in tabes first affects the 
nerve tubes and, perhaps, the cells of the central sensory 
nervous system, then the neuroglia and the vascular 
system, opinions differ as to paretic dementia. Some au- 
thorities, noticeably Magnan, hold that the disorder is es- 
sentially an interstitial peri-encephalitis. Others, like 
Joffroy himself, hold that the disorder affects the nerve 
cells and tubules, although just how, has not yet been satis- 
factorily settled. For others, who, like Raymond, see in 
paretic dementia but an interstitial inflammation, and in 
tabes but a parenchymatous change, the relation between 
the two disorders is easily settled. For those, however, who, 
like Joffroy, regard both disorders as resulting from a 
parenchymatous inflammation, the question is stil^in sus- 
pense. It must be admitted, Joffroy states, that tabes at the 
outset is characterized by a definite lesion of the central 
sensory system, while paretic dementia strikes haphazard, 
as it were, the motor, psychic and trophic systems, affecting 



40 NEUROLOGICAL. [Sept., 

less frequently and more slightly the sensory system. In 
JofFroy's opinion the co-existence of paretic dementia and 
tabes in the same subject is an inter complicatory coinci- 
dence ; similar coincidences exist between paretic dementia 
and disseminated sclerosis, organic hemiplegia and other 
neuroses. Cases exist, however, he admits, which present 
symptoms common to both disorders. The two neuroses 
are related ; not sisters, but first cousins. Predisposition to 
both appear in the same family, and syphilis may excite 
both. Raymond, in discussing Joffroy's opinions, said that 
they differed only in minor details. It could not be posi- 
tively affirmed that in either paretic dementia or tabes 
the lesion was primitively parenchymatous or primitively 
interstitial. There were merely strong presumptions in 
favor of the primitively parenchymatous character of the 
lesion in tabes. Raymond had used the term interstitial 
encephalitis in its current sense without reference to the 
primitive lesion. He did not believe, however, that symp- 
toms of tabes could appear in paretic dementia unless they 
resulted from tabetic lesions. He agreed with Joffroy 
that both disorders were nearly related and that syphilis 
could precipitate the occurrence of either in predisposed 

SUbjeCtS. j. Gi KIERNAN. 

Tabes and Paretic Dementia. — Dr. Reudu (Mercred. 
Med., June 25, 1892) concludes that because paretic 
dementia attacks an ataxic, or vice versa, there is no reason 
for placing these neuroses in a special class, albeit new symp- 
toms may result from their co-existence. The two dis- 
orders are pathological relatives. j. G . kiernan. 



Locomotor Ataxia, according to Dr. Raymond, (Prog. 
Med., June 11, 1892) is a disorder of ripe age which rarely 
attacks children or old men, but is sensibly more frequent 
in men than women. Neuropathic congenital predisposi- 
tion plays a part in certain cases, but the disorder is rarel} 7- 
the direct product of heredity. Exposure to cold and 
moisture, forced marches, venereal excess and grave traum- 
atisms, sometimes seemingly play a part in its causation. 
Such cases are rare compared with those occurring in 
luetics, sometimes without apparent exciting cause. The 
vast majority of tabetics have been luetic. Lues, how- 
ever, is not absolutely essential to the production of loco- 
motor ataxia. 

J. G. KIERNAN. 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 41 

Hereditary Ataxia. — Dr. Chr. Leegarda describes three 
cases of hereditary ataxia in three members of the same 
family. The parents were healthy and had always been 
so. None of the parents had suffered from any sickness of 
importance, neither had they been addicted to drink. They 
had had ten children in all, of whom eight were living. 
The members alive are : Ole, 32 years of age, a smith, 
married, and has a healthy child 8 months of age ; Anne, 
29 years of age, unmarried ; Nils, 25 years of age, married 
and childless ; Karen, 23 years of age, unmarried and suf- 
fering from hereditary ataxia ; Kristian, 20 years of age, 
unmarried, a sufferer from hereditary ataxia ; Severion, 18 
years of age, well and unmarried; Ludvig, 16 years old 
and a wood-chopper; Karl Johan, 13 years of age, and 
afflicted with Friedreich's disease. The original gives the 
complete history of each case. The hereditary origin of 
the disease is unmistakable in all the three cases, without 
there being anything in the parents or the relatives to point 
to a hereditary entailment. None of the patients present 
the slightest signs of deficient development. The disease 
made its appearance without any apparent cause, at an 
age varying from the eighth to the fourteenth year. It 
began with slight feverish symptoms and trifling pains, and 
soon passed into the progressive chronic stage. The 
ataxia is the most prominent symptom. The two brothers, 
Karl and Kristian, pass the day in their chairs. Karl Johan 
still crawls about, but in an unsteady and zigzag manner. 
Besides the usual spinal ataxia there is a trace of the cere- 
bellar form in the two oldest, apparent by the .absolute 
loss of equilibrium, and a tendency to walk in a zigzag 
manner in the younger. But besides these two peculiari- 
ties, there is a decided spastic element in the movements of 
the patients, and the muscular tonus is good while at rest, 
even being somewhat increased. This may be explained 
by an implication of the pyramidal tracts, and is the more 
important as the contrary holds good in tabes dor- 
salis. In Kristian there is a slight tendency to club foot, 
which would also come under this same condition. The 
muscular sense is much better than one would expect to 
find, especially while the patient is lying abed. When 
standing, or during walking, the equilibrium is lost entirely 
when the eyes are closed. As in tabes, the tendon reflex is 
wanting, but the cutaneous reflexes, on the contrary, are 
present and may be very distinct. The symptoms are espe- 



42 neurological. [Sept., 

cially prominent in the lower extremities, and only a little 
to be seen in the upper. Speech is only slightly altered in 
Karl Johan, and nystagmus is to be observed in none of the 
patients. Two of them have scoliosis. Although the 
lower limbs are so useless, the general strength is good and 
the resistance striking. In Karen, only, is there to be ob- 
served a slight decrease in the strength of the ilio-psoas 
muscle on both sides, and this also probably holds good of 
the remaining pelvic muscles, especially of the glutei. All 
the senses are good in all the patients, only Karl Johan 
having a slight narrowing of the field of vision. It may 
be added, for the sake of completeness, that the affection 
runs its course without pain; that atrophy and electric 
changes in the nerves and muscles are lacking, no trophic 
symptoms of any kind being present, and that the bladder 
and rectum are uninvolved, and the complete picture of 
hereditary ataxia is present. — (Norsk Magazin for Laegevid- 
enshaben, No. 5, 1892.) 

FRANK H. PRITCHARD. 

Primary Myopathy. — Dr. Peterson presented a case of 
primary myopathy before the New York Neurological 
Ass'n, at a meeting held on June 7. Patient aged forty- 
five years. Four years and a half before, patient had 
noticed a drooping and weakness of shoulders. Attributed 
this to his hard work as a mason. This weakness had 
gradually increased and spread to other parts of the body. 
The most striking feature at first sight was the "winged 
scapula" of serratus paralysis on both sides. Besides the 
serrati there was complete wasting of the sternal portion of 
each major pectoral, and there was marked diminution in 
size of both long supinators, of right triceps and biceps, of 
both trapezii and of right thigh and buttock. There was 
also slight asymmetry of mouth and forehead, as if right 
half of face were somewhat involved. As was to be seen on 
examining patient, the forearms and hands were absolutely 
free from the disease. The deltoids were large as compared 
with the wasted muscles about shoulders ; they were very 
firm and might possibly have been hypertrophied. Both 
calves were comparatively large. There was no anaesthesia 
anywhere and there were no fibrillary twitchings. Knee- 
jerks and wrist-jerks perfectly normal. All muscles reacted 
to faradism, but there was a quantitative change in the re- 
action in direct proportion to amount of wasting. The 
case was interesting because of its rarity. It was, of course, 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 43 

not an Aran-Duchenne, or peroneal type of progressive 
muscular atrophy, but a primary myopathy, and the 
only question in the mind of the speaker was, whether to 
consider it an Erb's juvenile form, or a Landouzy-Dejerine 
type. Dr. Sachs thought that the case presented pretty 
distinctive features of primary dystrophy, rather than of 
any other form. He had seen two cases of the juvenile 
type of progressive muscular atrophy in adults which 
corresponded in many particulars to the one presented by 
Dr. Peterson.— (New York Med. Jour., July 16, 1892.) 

B. M. CAPLES. 

Phlegmon of the Thigh, with Extensive Denudation 
of the Sciatic Nerve. — The patient fell upon a pitch fork, 
one prong of which ripped up the muscles of the back of 
the thigh from the knee almost to the buttock. In enlarg- 
ing the wound by opening fistulous track, the nerve was 
found lying at the bottom of the wound denuded to an 
extent of 20 cm. An extensive phlegmon developed so 
that the nerve ran through a pool of pus. During the first 
week the nerve looked normal and there were no signs of 
irritation. During the second week the nerve lost its luster 
and became of an opaline grayish color. Its motor and 
sensory functions below the knee were normal. Symptoms 
of irritation, in the shape of fibrillary twitchings and 
rheumatoid, radiating pains appeared and persisted until 
the end of the sixth week. During the third week, the 
sheath of the nerve sloughed and separated. At this time 
the nerve-trunk was painful on pressure to its exit from the 
pelvis. At the end of the fifth week, the nerve had become 
covered by granulations. Although the nerve was bathed 
in pus for four weeks there was at no time any interruption 
of its function. — (Dr. Buschke, Deutsche Med. Wochenschr., No. 
15, 1892.) 



G. J. KAUMHEIMER. 



Compression Myelitis Associated with a Columnar 
Area of Necrosis Extending a Considerable Distance 
above Compressed Portion of the Cord. — Dr. Ira Van 
Gieson presented microscopical specimens from the above 
case before the New York Neurological Ass'n. Patient was 
a middle-aged man, who had been run over by an ice cart, 
sustaining a fracture in lower dorsal region. Survived 
accident two and one half months. During this time there 
was an extreme degree of paraplegia and very extensive trophic 



44 neurological. [Sept., 

changes, giving rise to enormous bed-sores. One of these 
sores extended frorn sacrum upward between scapulae, while 
there were ulcers over heels and very deep ones extending 
even between the calf muscles. At autopsy nothing was 
found worthy of note except the condition of spinal cord. 
This was so greatly flattened in eighth or ninth dorsal seg- 
ment as to measure only three by six millimeters. Above this 
flattened portion in the dorsal region, and in seventh 
cervical segment, was a columnar area of softening situated 
in posterior columns and involving caput of right posterior 
horn. On cutting cord transversely the softened material 
flowed out leaving a sharply rimmed cavity. Microscopical 
examination of flattened portion showed cord had degen- 
erated into a fluid mass contained within membranes. The 
columnar area of necrosis was readily seen with a low mag- 
nifying power. Dr. Van Giesen also referred to a similar 
case which had been reported by C. L. Dana, and exhibited 
the plates illustrating this one. He reported this case, 
because with one exception it appeared to be unique, and 
because he was unable to understand the nature of this 
process. — (Med. Record, July 9, 1892.) 

B. M. CAPLES. 



Multiple Neuritis. — Dr. W. H. Gilbert read a paper at 
a meeting of the Congress of Neurologists held at Baden- 
Baden, on two cases of polyneuritis which presented some 
striking features. The first was that of a man, aged 56, 
member of a "very nervous family," and himself of very 
irritable and hasty temper. In February, '91, he had 
an illness, thought to be peliosis rheumatica, in which he 
suffered great pain, followed by cutaneous anaesthesia and 
muscular paralysis of extremities. Improved somewhat 
under electrical treatment and massage, but when first seen 
by author was emaciated to an extreme degree. There 
was general muscular atrophy. Abolition of patellar and 
plantar reflexes, while the nerve-trunks, which could be felt 
through the attenuated lower limbs, were the seat of pain- 
ful nodular swellings. Some loss of control over the bladder 
and rectum. Under treatment improved slightly so that 
he could walk better, and gained a little in weight. An at- 
tack of diarrhoea, brought on by exposure to cold, rapidly 
reduced his strength and he died July 9. The other case 
was that of a woman, 32 years of age. On Feb. 2, 1892, 
swallowed a large quantity of "Schweinfurt green" with 
suicidal intent. Recourse to the stomach-pump and other 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 45 

measures averted a fatal issue. Then ensued great pros- 
tration and severe gastro-enteritis, lasting four days, fol- 
lowed by symptoms of paralysis of limbs with severe 
paroxysmal pains, especially in the right limbs. Numb- 
ness of the fingers, sensation of cold, profuse sweating and 
insomnia. This was the condition when patient came 
under Dr. Gilbert's care on April 3, when she could only 
move slowly and with great difficulty. Complained of 
stiffness in legs and great weakness. Plantar and patellar 
reflexes were exaggerated; there was foot-clonus on right 
side ; only moderate anaesthesia. This patient, who 
presented in a striking degree the effects of arsenical 
neuritis, entirely recovered. The author stated that in 
each of these cases the motor functions were more involved 
than the sensory. — (Lancet, July 16, 1892.) 

B. M. CAPLES. 



The Pathogenesis of Epilepsy from Spinal Lesions. — 
Colella, Italian Freniatrical Soc, 1891. (Abst. Archivia 
Italiano.) — The objects of the author in initiating this inves- 
tigation were: 1. To observe in what species of animals 
are produced epileptic convulsions from various lesions of 
the cord, and to study the mysterious relations that exist, in 
subjects become epileptic, between certain regions of the 
spinal cord and certain tracts of the skin of the face, or of 
the neck (epileptogenic zones). 2. To find out in animals, 
thus made experimentally epileptic, what follows the 
electrical irritation of the excitable zone of the cerebral 
cortex. 3. To inquire what phenomena follow the super- 
ficial, or rather deep decortication of the excitable zone of 
the cerebral cortex of the two sides in animals already 
affected with spinal epilepsy. From the experimental facts 
observed the author concludes: 1. In all the species of 
animals experimented upon (dogs, guinea-pigs, pigeons) 
various injuries of the spinal cord may be the cause of a 
very marked epileptiform disorder. 2. Only in man and 
in guinea-pigs is it possible to find special epileptogenic 
zones in certain regions of the face or neck, irritation of 
which gives rise to the epileptic convulsion. There exists, 
nevertheless, in the guinea pig a mysterious relation 
between certain parts of the spinal cord and this epilepto- 
genic zone. 3. As regards the electrical irritation of the 
excitable tract of the cerebral cortex, the least stimulus ca- 
pable of causing a movement applied in the same manner 



46 neurological. [Sept., 

to homonymous points of the two hemispheres, while it 
gave rise to motor reaction when they thus excited the 
centres of the greatest functional activity for the sound 
limbs, did not cause it when the stimulation was made of 
the cortical centres from which is derived the major part of 
the motor innervation of the paralyzed extremities. 4. The 
electrical stimulus of least intensity capable of causing a 
convulsive attack by exciting the cortical motor zone, cor- 
responding to the injured half of the spinal cord, when 
applied in the same manner, and to homologous points of 
the excitable cortical region of the opposite hemisphere, 
appears to provoke irregular movements, which cease 
with the interruption of the stimulus. 5. Such electrical 
irritation of minimum intensity, sufficient to cause epileptic 
attacks in animals with spinal epilepsy, applied to identical 
parts of the excitable region of the cortex in healthy 
animals of the same species, causes, ordinarily, phenomena 
identical in nature. (The propositions 4 and 5 are hazarded 
with great reserve and some exceptions were found to them 
by the author in his experiments; account should be taken 
in this regard of the many causes of error arising, especially 
of cortical exhaustion consecutive to repeated excitations of 
the same motor regions, or to epileptic attacks). 6. Experi- 
ments made of rather deep decortication of the excitable 
region of the cerebral cortex of the two sides, as well as the 
similar ones undertaken on healthy animals, in which the 
spinal lesion was produced only after the removal of the 
excitable zone of the two cerebral hemispheres, are incom- 
plete. No results, therefore, can be reported for the present: 
the motor zone of the cerebral cortex undoubtedly repre- 
sents the central and necessary organ for the production of 
epileptiform convulsions, and thence all these should be 
referred to a common pathogenesis; but the presence, or the 
excitation of this cortex,may be only one of the conditions of 
the development of these epileptic attacks, in the sense of an 
influence that it may exert over the inferior nervous centres. 

H. M. BANNISTER 



Caloric Epilepsy. — Dr. Benedikt relates the case of a 
lad of fifteen, who, from one to several times daily, would 
have an elevation of temperature attended with loss of 
consciousness whenever 42.4 degrees to 43 degrees C. were 
reached. As the attack, which lasted from ten to thirty 
minutes, came on, the patient assumed a staring expression. 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 47 

As soon as consciousness returned there was always com- 
plaint of contraction of the nuchal muscles, prostration and 
visual hallucinations. No cerebral symptoms during the 
intervals. Moderate splenic enlargement, slight albumin- 
uria and increase of white blood corpuscles were found. 
After cautery points over the coronal suture, and sodium 
iodide, the fits gradually ceased. The author looks upon 
the case as one of microbic or ptomainic intoxication. — 
(Brit. Med. Jour., May 14, 1892.) 

B. M. CAPLES. 

Albuminuria and Epilepsy. — Drs. J. Voisin and A. 
Peron conclude (Arch, de Neur., May, 1892) that albumin- 
uria results in certain epileptics. It bears no relation to 
the type of the neurosis or to the frequency of attacks. 
Status epilepticus has been, in their experience, always ac- 
companied by albuminuria. Albuminuria, while constant 
in the same subject, is fleeting and variable in quality. It 
shows itself especially in the first two hours after con- 
vulsive attack and appears to have a constant relation with 
facial congestion. 

J. G. KIERNAN. 



Friedreich's Disease in an Epileptic Imbecile. — Dr. 
Szczypiorski has observed (Ann. de Medico- Psych., May- 
June, 1892) a case of Friedreich's disease in an epileptic 
imbecile. There was no record of ataxic heredity. 

J. G. KIERNAN. 

Taste and Smell, according to Fere, (Prog. M&d., Aug. 6, 
1892) are deficient in 60 per cent of the epileptics. The 
bromides do not improve the patient in these particulars. 

J. G. KIERNAN. 

Hysteria in Infancy. — Chaumier believes that certain 
neurotic manifestations of young infants are hysterical in 
character. Convulsions in children have usually been 
regarded as manifestations of a special disorder, which may 
result from indigestion or may take the place of the chill or 
delirium in the adult. The author explains his somewhat 
novel theory by assuming that this is not always the fact. 
The apparent fits of passion without sufficient cause, 
accompanied by crying, he regards as the mildest form of 
this hysterical disorder. In other cases the child will stiffen 
the limbs, face will become turgid, and the bod}^ will be 



48 neurological. [Sept., 

seized with a distinct tremor. In a more serious form the 
child suddenly becomes quiet and seems for a moment to 
be unconscious. The mouth is open. The body usually 
becomes rigid. Occasionally there are no contractions and 
the body becomes relaxed and limp. These attacks are 
usually known as fainting spells, and are frequent in chil- 
dren who later develop decided hysterical symptoms. In 
older children undoubted hysterical manifestations are not 
uncommon. The child faints, or half loses consciousness, 
the limbs are often rigid, but may be relaxed, and the eyes 
are moved in a convulsive manner. Spasmodic movements 
sometimes occur which may be taken for actual convul- 
sions.— (New York Med. Jour., July 23, 1892.) 

B. M. CAPLES. 



Hysteric Hyperpyrexia. — Dr. Vizioli has had under 
observation (Rev. Intrt. de Biblio, July 28, 1892) the case of 
an hysterically neurotic female who had, after several days of 
toothache, hyperpyrexia, which irregularly oscillated be- 
tween 98.5° F. (morning) and 101.30° (evening) during one 
week. The patient had an attack of hysteric lethargy, 
whereupon the temperature, coincident with slow pulse 
and respiration, rose on the first day to 105.8° F., on the 
second, to 110.3° F., and on the third to 113° F., at which it 
continued until early in the third week when it suddenly 
fell to 93.2° F. 

J. G. KIERNAN. 

The Association of Hysterical Trembling and An- 
orexia Nervosa. — Dr. Lloyd read a paper on this subject 
before the Amer. Neurological Ass'n, in which he reported 
the case of a young woman who was suffering with a pe- 
culiar rhythmic, constant tremor, which was, however, not 
paralysis agitans. The tremor occurred in waves of exac- 
erbation and opisthotonic spasms every minute or so. The 
patient had hysterogenic zones, pressure over which caused 
the spasms ; also the condition described by Gull as ano- 
rexia nervosa. By mistake a large dose of ordinary saltpetre 
had been given instead of sulphate of magnesia. While no 
harm had directly resulted from this error, the mental dis- 
turbance had been such that regurgitation of food had set 
in, and this had become the most pronounced complication 
in the case. Patient was found lying upon her side with 
cloths under her chin to catch the regurgitated material. 
Emaciated to the last degree. There was no atrophy, 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 49 

but simply inanition. This condition was followed by true 
hysterical retention of urine, lasting sometimes for two 
days. After the patient had been removed to hospital, 
tremor greatly subsided and regurgitation of food entirely 
stopped.— (Med. Record, July 30, 1892.) 

B. M. CAPLES. 

On Tremor. — 1. The observations made in my clinic 
during the past year corroborate the result of physiological 
investigation : that tremor is of cerebral origin. In fact, it 
can only be caused by a non-destructive lesion of the 
psychomotor substance or the cerebro-pyramidal tract. 2. 
As in chorea, if tremor involves both sides, it is a combina- 
tion of two unilateral affections. It frequently occurs 
unilaterally at first, and the tremor of one side may show 
a difference in intensity or character from that of the other. 
Generally the tremor due to a general cause (nervous, hys- 
terical or toxic tremor) is stronger on the left side. 3. 
Electric irritation, by the application of the electrodes to 
the head, produces a considerable modification [of the 
tremor in paralysis agitans. With the anode on the sternum 
and the kathode over the left Rolandic region, the oscilla- 
tions of the right arm, which extended over 6 to 
7 cm., extended 9 to 10 cm., with 5 m. a. of current, 
and in 10 minutes to 11 cm.; 5 minutes after removal 
of the current the tremor was less than usual. A 
similar result followed the reverse application of the 
current. 4. A diminution of the tremor (in the 
right arm) was produced by the application of an ice- 
bag to the left Rolandic region, which diminution was still 
noticeable 47 minutes after the ice-bag was removed. 5. 
The author has taken tracings of the tremor of a hand in 
3 healthy individuals while the other hand was supporting 
a weight of from 2 to 5 kilogr. The tremor increased with 
the weight and also if the individual's mind was busied at 
the same time. 6. Of all the various remedies recom- 
mended for this symptom arsenic seems to be the most 
successful. This remedy is also useful in neurasthenic 
tremor. — (Prof. E. Renzi, Naples, Wien. Med. Wochensch., No. 
14, 1892.) 

G. J. KAUMHBIMER. 

A Case of Hemichorea Followed by Partial Hemi- 
plegia in a Child Four Years of Age. — Piggott reports 
the following case which he thinks, in all probability, de- 



50 



NEUROLOGICAL. 



[Sept., 



pendent upon capillary embolism. Patient suffered more 
or less from convulsions during dentition. At completion 
of the fourth year was attacked with influenza, which was 
succeeded by marked choreic movements in the left upper 
extremity, facial muscles on left side being next affected. 
Disease assumed a decidedly progressive character and ulti- 
mately reached left lower extremity. Often present during 
sleep. Hypophosphites, liquor arsenicalis and cod-liver oil 
were prescribed. Marked improvement, which was of brief 
duration. Decided evidence of hemiplegia soon manifested 
itself ; paralysis of the left facial muscles, partial ptosis and 
considerable photophobia, with loss of power in the left 
arm. Later, conjunctiva of the left eye totally insensitive. 
Diminished sensibility in right conjunctiva; marked 
trismus, jaws being firmly closed. Tonic contraction of the 




forearm and both legs, 

s gradually increased. 

coma. Post-mortem 

thinks the tendency 

onvulsions attendant 

2-) 



B. M. CAPLES. 



extensor muscles 
left being mos 
Patient passe " 
examination 
to brain mi 
upon dentitio 

Chorea. — Dale has"STriTeaat the following conclusions : 
1. Although chorea is best defined as a functional disease 
it cannot be called a symptom. 2. From the phenomena 
of hemichorea and its relation to hemiplegia, we may as- 
sume that the seat of the lesion is in the sensori-motor 
ganglia at base of brain. 3. The disease frequently occurs 
after acute or sub-acute rheumatism, but many cases have 
no connection with rheumatism in any form. 4. The 
cases of chorea in which cardiac murmurs are found have 
for the most part been preceded by rheumatism, but this is 
not invariably true. 5. Some children are strongly sus- 
ceptible in certain nerve centres, which are easily influenced 
by physical causes, and in these children chorea is very 
often developed. 6. In the great majority of cases complete 
recovery may be expected. In treatment the author relies 
chiefly upon diet, a cold shower bath, iron and arsenic. — 
(New York Med. Jour., July 23, 1892.) 

B. M. CAPLES. 



The Vertigo of Arterio-Sclerosis. — Dr. Archibald 
Church says that it is only of late years that arterial 
changes have been given importance in pathology and 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 51 

in clinical medicine. The degeneration of senility, the 
modifications found in gout, rheumatism, chronic metallic 
poison, syphilis, and which are associated with alcoholism 
and Bright's disease, make it imperative that we recognize 
at the earliest possible moment any change in the arteries 
which may in early stages be amenable to treatment. Here 
we have to deal with a pre-atheromatous condition. We 
extract the following from the author's article: "When a 
man, past the prime of life, without any previous serious 
illness becomes suddenly faint, has a swimming in the 
head, a feeling of giddiness, of distinct gyration, of dark- 
ness and impending death, one or several of these sensa- 
tions, he usually at once seeks advice in grave apprehen- 
sion, sometimes well founded, of approaching cerebral 
apoplexy, and usually gets a cholagogue cathartic, or is told 
that his stomach is wrong, and sometimes is told rightly. 
But cases are constantly presenting themselves in which 
such vertiginous attacks are happening at shortening inter- 
vals ; the patient gives up his tobacco, his spirits, if he is a 
drinker ; cuts down his meat, takes to some of the many 
waters recommended ; has Turkish baths, and gains only 
moderate relief or none at all. If he is carefully examined 
he will probably present a well-defined tortuous frontal 
artery, a distinct arcus senilis, a strong, even a clanging 
second sound of the heart, sometimes reduplicated, and 
gives a sphygmogram indicative of increased arterial ten- 
sion. The pulse may be abnormally slow or arythmic, the 
urine scant, and a trace of albumen is not rare. He finds 
that exertion of a moderate amount precipitates the attack, 
that he cannot endure a temperature at all above the 
usual, and often a change of position from recumbency to 
the upright is the occasion of a "blurr" or of giddiness. 
The attack itself is, as already indicated, widely variable 
in different patients, but is usually consistent with itself for 
the given individual. A fullness and throbbing in the 
head, a feeling of heat in the scalp and a blurr before the 
eyes are usually mentioned, and at such times marked pale- 
ness is noticed, followed, as a rule, by considerable redness 
of the face. There is a tendency to get into the open air 
and badly ventilated or close apartments are unendurable. 
An habitual smoker will sometimes find tobacco-smoke re- 
pugnant. In more severe forms the patient may stagger, 
or gradually sink to the ground ; he cannot speak for a 
few seconds though consciousness is rarely completely lost. 



52 neurological. [Sept., 

The recumbent position is usually sought or the patient 
clings to some object, and after a period of from five to 
twenty minutes the feeling passes away, leaving him rather 
languid, with an inclination to sleep and usually mentally 
depressed and apprehensive. At first he attributes the at- 
tack to anything and everything that in his estimation 
can cause a departure from health, and usually establishes 
a close watch upon his diet, habits and mode of life, is in- 
clined to avoid exercise or exertion of any sort, fearing to 
precipitate an attack, or to go by himself on the streets, and, 
in short, becomes an invalid with hypochondriacal tenden- 
cies. The diagnosis is often one of extreme difficulty in 
spite of the hasty contrary statement by a recent American 
writer, and I have known the symptomatic vertigo con- 
fused with Menier's disease by a very competent specialist 
in nervous diseases ; for it may, as in that particular instance, 
be of a systemized character, that is to say, marked by a 
sensation of falling in a given direction or of being rotated 
in a constant manner to the right or left, and even asso- 
ciated with a suggestive stagger. If to this a little middle 
ear catarrh is added, a diagnosis of aural vertigo might 
easily be reached, but a closer and somewhat wider examin- 
ation will detect the integrity of the auditory nerve and 
the presence of the arterial fibrosis with the underlying 
predisposition of alcoholic excess, syphilis, gout, rheuma- 
tism, chronic lead infection, or other constitutional state of 
etiological significance." — (Chicago Med. Recorder, July, 1892.) 



Afebrile Typhoid with Severe Cerebral Symptoms. — 
A girl, aged 9, was taken sick with headache, chill and fever 
Nov. 15, and a few days later had to remain in bed. She 
soon became so noisy and restless that she was transferred 
to the hospital Nov. 26. On admission she was comatose, 
but screamed and tossed about incessantly. The slightest 
touch called forth screams. Pupils were widely dilated and 
reacted very slowly. P. 180, T. 36.5 Q C. The stools, to the 
number of 3 to 4 daily, were passed into the bed. 
Meningitis was suspected. The temperature never rose 
above 39° C, which was observed twice in the morning 
hours. The treatment consisted of the ice-cap and of small 
doses of chloral at night. On the 17th day of the disease 
she became more quiet so that an examination was possible. 
This showed a swollen spleen. From this time on a 
gradual improvement took place. On the 25th day the 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 53 

child became conscious. From the 20th to the 30th day- 
numerous furuncles developed all over the body. Convales- 
cence was interrupted by a rubeolous eruption without 
fever, but otherwise progressed favorably. The diagnosis 
was surrounded by a great deal of difficulty, but the history, 
as well as other details, at last determined the diagnosis. 
These cases, while quite rare, are also marked by a very 
large mortality. Fraentzel and Strube have reported 
similar cases. The great depression of temperature (in this 
case as low as 36° C.) is attributed by Liebermeister to the 
action of the virus on the heat-regulating centres. In his 
large experience the latter has seen but ten such cases. — 
(Dr. Sigmund v. Gerloczy, Deutsche Med. Wochensch., No. 15, 
1892.) 

O. J. KAUMHEIMER. 



Enteric Fever; Right Hemiplegia with Aphasia; Re- 
lapse; Death. — Dr. Don kin places this case on record on ac- 
count of the exceptional occurrence of hemiplegia with enteric 
fever. Patient had usual symptoms of enteric fever, except 
that bowels had not moved for several days ; an enema was 
ordered, and at 6:00 p. m. when nurse was about to adminis- 
ter it, found patient with much impaired consciousness and 
unable to articulate. Examination showed drooping of left 
eye-lid and considerable paralysis of right arm and leg. 
Swallowing difficult: urine passed involuntarily. During 
next few days paralysis became complete and there was con- 
siderable loss of sensibility in affected limbs. Breathing 
somewhat labored. Temperature rose to 105; patient died. 
Necropsy showed the brain substance pallid and sulci deep. 
Left carotid was distended with a softish, dark clot which 
extended to its principal branches, the middle cerebral being 
apparently most affected; clot was confined to Sylvian fissure. 
The supply area of the middle cerebral was extremely dis- 
organized, the softened parts being the left corpus striatum, 
island of Reil, the operculum, the anterior fourth of upper 
temporo-sphenoidal convolution, and wall of the lateral 
ventricle in more than its front third. Corpus striatum 
was of a greenish-yellow hue, and only kept in position by- 
its attachment posteriorly to optic thalamus. Elsewhere 
surrounding nerve tissue was broken down flocculent 
detritus. This disorganization affected whole of anterior 
cornu and wall of ventricle as far back as front of optic 
thalamus, latter somewhat softer than normal, and chiefly 



54 neurological. [Sept., 

affected in its outer front part. Rest of the cerebrum, cere- 
bellar pons and medulla were, except that the puncta 
vasculosa were large, not noteworthy. Vessels of pia mater 
normal to the naked eye. — {Lancet, April 23, 1892.) 

B. M. CAPLES. 

Pathology of Addison's Disease. — Fleiner reports two 
cases of AddisoD's disease with autopsies, and comes to the 
conclusion that the pathology consists in a chronic inflam- 
mation arising in the suprarenals and extending to the 
sympathetic system. This was most fully developed in the 
semilunar, less so in the dorsal and cervical ganglia. He 
found an increase in the connective tissue of the ganglia, 
with atrophy of the nerve cells and an extensive degenera- 
tion of the splanchnic and sympathetic nerves. Lesions of 
the spinal cord were present, but the author does not know 
whether they were accidental or due to extension of inflam- 
mation along the sympathetic fibers through the posterior 
nerve roots. — Deutsche Zeitschrift ftir Nervenheilkunde, May, 
1892.) 

JOS. KAHN. 

Syphilitic Hemiparaplegia. — Dr. Armstrong has an 
article in the Med. Record of July 9, with the above title. 
He cites the case of a man, aged fort}^-one, seaman by occu- 
pation, who came under his observation in June, 1888, suf- 
fering with pain in his hips, knees and feet, that had 
existed for two weeks. Two and one half years before 
admission had had a chancre that was followed by a 
papular eruption for which he had been insufficiently 
treated. Placed on suitable treatment and discharged in 
July, free from pain. Was readmitted in Jan., 1889. 
Suffered with pains in the shoulders, arms, back and chest. 
Had an indurated ulcer on side of tongue that had been 
present for some time. Incontinence of urine for two 
weeks. Was at once placed upon iodide of potash treat- 
ment. On Feb. 4 there was a sudden paralysis of the right 
lower extremity. The dynamometer showed a compression 
force of 35 kilogrammes in right hand ; 30.75 kilo- 
grammes in left. ^Esthesiometer showed normal tactile 
sensation on the anterior surface of the body until the 
thighs were reached. On the left thigh sensation was 
diminished from inguinal region until in its lower portion, 
and in leg there was a complete loss of sensibility. On 
anterior surface of right thigh and leg slight diminution of 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 55 

sensibility. Posteriorly same results were obtained, except- 
ing that anaesthesia commenced at the left nates. Diminu- 
tion of thermal sense in left extremity. Incontinence of 
urine and fseces. The symptoms indicated a lesion of the 
cord in region of the last thoracic or first lumbar vertebrse. 
Daily increasing doses of iodide of potash were given; later, 
limited to 60 grains a day with the addition of syrup iodide 
of iron, as patient was quite anaemic. Patient improved. 
Feb. 4 could walk alone. March 24 patient was dis- 
charged. Able to be on his feet all day and general condi- 
tion very good. He went to sea, was away several months 
and unable to continue the specific treatment. Re- 
turned to hospital with well-marked symptoms of posterior 
spinal sclerosis. The author thinks the probability of re- 
lapse in such cases is very great, especially as either the 
blood vessels or meninges may be affected in other localities 
and await a suitable time to indicate existence of patholog- 
ical process that is going on. The necessity of specific 
treatment is apparent. In all cases of syphilis affecting the 
nervous system every precaution in therapeutics and hygiene 
should be observed. — (Med. Record, July 9.) 

B. M. CAPLES. 



Chronic Hydrocephalus and Hereditary Syphilis. — 
Dr. Jul. Heller attended at the birth of a child which, at 
that time, was apparently healthy. At the age of four 
weeks it became necessary to supply a wet nurse, as rapid 
emaciation occurred. The child improved for a while, 
when enteritis set in and resisted all treatment. At the 
seventh week a number of pigmented scaling macules were 
found on the soles, palms and extremities. Under sub- 
limate baths and calomel the child became perfectly well 
in four weeks. He next saw the child at the age of six 
months. The head was then very large, with tortuous 
veins running over the scalp and with widely gaping fonta- 
nelles. All measurements were from 2 to 3 cm. larger 
than those given as normal in text books. The organic 
functions were normal, the special senses were dulled, but 
not abolished. No signs of rickets could be discovered. 
Iodide of potassium in small doses, with tonics, was given 
for four months. At this time a great change had taken 
place. The venous plexuses in the scalp had disappeared, 
the hair began to grow, the fontanelles had almost closed, 
the bones of the cranium had become much firmer, and 
the face had almost caught up to the head in growth. The 



56 neurological. [Sept., 

further development of the child took place slowly, but in 
a normal manner. No sign of syphilis could be detected 
in the mother or nurse. Infection after birth can be ex- 
cluded. The atrophy was probably due to a luetic enteritis, 
and the eruption appeared only two weeks after the employ- 
ment of the nurse. The father could not be examined. 
The authorities on diseases of children either ignore or 
deny the relationship of the two diseases. Ziegler and 
Eichhorst, however, admit its possibility, while Veronese 
and Fournier believe them to be associated quite often. 
Heller gives abstracts of ten cases which he has found re- 
corded, although in only one, specific treatment was of any 
avail. He points out that the presence or absence of a 
specific taint should be carefully sought for in all cases of 
chronic hydrocephalus in infants. — [Deutsche Med. Wochensch., 
No. 26, 1892.) 

G. J. KAUMHEIMEB. 



Pachymeningitis Tuberculosa Circumscripta. — While 
secondary infection of the dura mater from tuberculous foci 
in the cranial bones and vertebral column is by no means 
uncommon, primary tuberculosis of this membrane is so 
rare that Gussenbauer has seen only the case which he now 
reports. C. W., aet. 21, was struck by a falling piece of 
wood upon the left parietal bone. The blow was not fol- 
lowed by an extravasation or pain, and he was not interrupted 
in his work. Four weeks after he felt severe darting pains 
in the right side of the head, followed by chills and a rise of 
temperature. Several weeks later diplopia, insomnia and 
pains in the nucha were complained of. A gland at the 
back of the neck became hard and painful. Some 7 to 8 
weeks after the blow a soft swelling appeared at the site of 
the injury, which very slowly increased to the size of a hen's 
egg. The chills became more frequent and violent and the 
swelling became hot and painful. The pains in head and 
neck, diplopia and insomnia receded as the swelling 
increased. Four months after the injury, the swelling was 
incised and pus mingled with shreds of necrotic tissue 
evacuated. The chills then became milder and less frequent, 
although a fistula remained. In October (he was injured in 
January) examination showed some dullness over the apex 
of the right lung. A fistula was found in a cicatrix, 10 cm. 
from the tip of the mastoid process, the same distance from 
the meatus and 9 cm. from the sagittal line. Palpation 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 57 

showed a hole in the cranial vault with a radius of 1 cm. 
from the fistula. The edges of the defect were sharply cut. 
The pericranium and scalp were not thickened or tender. 
Pulsation could be felt and seen. There were no brain 
symptoms. The absence of all symptoms for four weeks 
following the traumatism led Gussenbauer to reject the 
diagnosis of a direct injury. The whole slow course of the 
trouble, together with the watery pus discharged from the 
fistula and the tubercular habitus of the patient, tended to a 
diagnosis of tuberculosis. An incision crossing the fistula re- 
vealed a pulsating mass of granulations. The edges of the 
bony defect were as thin as a card, the diploe and inter- 
nal table being absent. In order to expose the entire mass 
the bone was nibbled away with bone forceps. As its periph- 
ery was reached, the diploe and internal table reappeared. 
When the limits of the new formation were reached, the hole 
in the skull measured 9.5 cm. from its anterior inferior to its 
posterior superior angle, and 7 cm. antero-posteriorly. A 
mass of fungus granulations was found lying upon the 
dura, gradually fading into healthy tissue at its periphery. 
With the sharp spoon the entire mass was removed, the 
external fibrous lamella of the dura coming away with it. 
After disinfection and suture recovery was prompt and 
uninterrupted. Microscopic examination showed the pres- 
ence of miliary tubercles containing giant cells. No 
attempt was made to close the bony defect on account of the 
liability to relapse. G., however, intends to attempt a 
secondary osteoplastic closure if no local relapse or develop- 
ment of tubercle in other organs occurs. At present' he 
wears a hard rubber plate. — (Prag. Med. Wochenschr., No. 9, 

LOoZ.) G.J, KAUMHEIMIB. 

A Study of Neurotic Eczema in Adults, by Dr. 
Barham. The author thinks that neurotic eczema is in itself a 
variety, as evinced by its location upon the extensor sur- 
faces, by the arrangement of its lesions, and by the course of 
the disease, its condition varying under circumstances which 
are certainly not local. He here discusses a few typical 
cases in which he says the superior lesion may be de- 
stroyed. The separate lesions may be described as patches 
composed of closely aggregated papules or vesicles, or both. 
In places the edges of the patches have coalesced, forming 
large areas of diseased skin with here and there an island 
of healthy tissue. In some lesions there is no scaling nor 



58 neurological. [Sept., 

weeping, the vesicles not being ruptured. Eruption on the 
legs presents the same appearance and general character- 
istics as on the arms. Among the disorders producing this 
condition, the most common, and presumably the one hav- 
ing most bearing on the disorder under discussion, is a gen- 
eral weakness of the nervous system. This the author noted 
in the history of every case except one, and in this,patient suf- 
fered from a disease generally acknowledged to be nervous 
in its origin. In most cases the eruption was preceded 
by a period of mental suffering. Whether the mental 
suffering was occasioned by prolonged sickness, trouble, 
anxiety or privation, the result was the same, neurasthenia. 
Among the functional disorders constipation, often obstinate 
and of long standing, is the most common. Other causes 
are disorders of the reproductive organs, and sickness involv- 
ing great strain upon the nervous system, as the grippe, 
and exposure* to extremes of temperature. Author 
thinks the evidence is against the direct action upon the skin 
of retained products of excretion, such as uric acid, etc., 
although he states that eczema may be present in rheu- 
matic and gouty subjects, but the appearance and course of 
the disease is different from that under discussion. That a 
vaso-motor disturbance is, in a great measure, responsible 
for the eruptions is, he believes, supported by the following 
features in the clinical history of the eruption : 1. The 
symmetrical location of the lesion. 2. The sharply de- 
fined margin of the affected area, which, in connection with 
the above feature points to a nerve influence in its distribu- 
tion. 3. The location of its lesions on extensor surfaces 
of extremities and on the face, this being the location 
chosen by erythema multiforme, rosacea, etc., which are 
admittedly of reflex nervous origin. 4. In a few cases 
the distribution can be shown to be confined to 
surfaces supplied by certain groups of nerves 
where the distribution was sharply limited. The 
spread of the eruption is never by a gradual extension of 
the areas of the separate patches, but by the formation of 
new lesions, in every respect retaining the true character- 
istics of the older ones. The eruption has a tendency to 
frequent relapses, for which often no immediate cause can 
be ascertained. The treatment should be both internal 
and local. Internal treatment should be directed first 
toward correcting any functional disorder present. The 
nervous system should be relieved as far as possible from 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 59 

any mental worries, business cares, etc. Any existing 
digestive trouble must be corrected. Any disorder of the 
reproductive organs that may be present must be corrected. 
In those cases where the congestion is marked, ergot gives 
good results applied locally in the form of an ointment. 
— {Med. Record, July 9, 1892.) 

B. M. CAPLES. 

Pathological Anatomy of Lepra An^esthetica. — Car! 
Looft, in Virchow's Archiv, reported two cases, with autop- 
sies, in which he found marked changes in the posterior 
columns of the spinal cord. In the first case the cervical 
portion was most affected ; in the second, the lumbar por- 
tion showed marked changes, while the cervical was not 
examined. In both cases the posterior nerve roots were 
much atrophied, and the ganglia of the spinal nerves pre- 
sented much fibroid degeneration with absence of medul- 
lated nerve fibers and changes in the nerve cells. Chronic- 
neuritis was found in the nerve trunks that were examined. 
The anterior horns of the gray matter and the anterior 
nerve roots were normal, and the posterior horns showed 
merely a suspicion of degeneration. The changes were 
much like those found in ergot poisoning. The author 
believes that the primary lesions are those of the posterior 
nerve roots and the ganglia of the spinal nerves. It is 
difficult to determine how much the symptoms are caused 
by the peripheral and how much by the central lesions. 
The paralysis is probably due to the peripheral neuritis, for 
the anterior horns of the gray matter and the anterior nerve 
roots are normal. — (Kronthal. Neurolog. Centralblatt, No. 14^. 
1892.) 

JOS. KAHN. 

Tetanus of the Head. — (Nerlich. Archiv fiir Psgchiatrie r 
Vol. 13, No. 3.) — Prof. Edw. Pose, in a monograph on 
tetanus, describes a peculiar form of the disease characterized 
by paralysis of the facial nerve and great reflex excitability 
of the muscles of the pharynx and larynx, which he calls 
tetanus of the head, or tetanus hydrophobic!] s. Nerlicb 
reviews the literature of the subject and reports a case of 
his own. He finds that the disease is due to injury in the 
region of the cranial nerves and that the first symptoms 
may occur either before or after the wound is healed. The 
time of onset varies from twenty-four hours to twenty-four 
days and averages about eight or nine days. In fatal cases 



60 NEUROLOGICAL. [Sept., 

the paralysis persists until death. Where recovery takes 
place the paralysis usually ceases with the tonic convulsions ; 
only in one case did it persist longer. The paralysis is 
generally found on the injured side. At the onset of the 
disease the clonic spasm of the masseter muscle is present 
only on the injured side, but soon the opposite side is also 
affected. The muscles of the pharynx and larynx are re- 
flexly affected, and this was considered the characteristic 
symptom of the disease by Edmund Rose. 

JOS. KAHN. 



Tetanus Due to Puncture of a Hypodermic Needle. 
— Osborne reports case of a man, twenty-four years of age, 
who consulted him complaining of slight pain in limbs, 
head and back, and a feeling of general malaise. Tempera- 
ture and pulse normal ; slight stiffness in muscles of the 
neck. Next morning increased stiffness about neck and 
also lower jaw and abdomen ; difficulty in protruding 
tongue and slight "risus sardonicus." Temperature, 98.6 ; 
pulse, 104. Patient denied the existence of a wound or 
sore anywhere. Was ordered full doses of chloral hydrate 
and morphine. Toward evening all symptoms more 
developed. Two days later tetanic convulsions very fre- 
quent and there was marked opisthotonos. Day following, 
temperature, 99.3 ; pulse, 112. Author found small sup- 
purating sore near right shoulder. Patient admitted that 
this was due to puncture of a hypodermic needle and that 
he was in the habit of injecting morphine hypodermically. 
Wound was inflamed and suppurating and about the size 
of a three-penny piece. The author thinks that this should 
impress the necessity of the most scrupulous cleanliness 
in the performance of even this small operation. Patient 
died.— (Brit. Med. Jour., July 9, 1892.) 



B. M. CAFLES. 



Intermittent Hysterical (?) Paralysis. — Dr. L. Bremer 
publishes the case of a boy, 16 years of age, who, apparently, 
had intermittent hysterical paralysis with hystero-epileptic 
•convulsions. Boy had had a fall at five years of age which 
resulted in a bad bruise on the right side of the skull, but 
no fracture. Several times he had had sudden attacks of 
paralysis of the left leg which lasted from a few minutes to 
several days, followed by recovery. Later had an attack of 
paralysis of this leg with the hystero-epileptic convulsions 
following. This time complete paralysis and anaesthesia all 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 61 

over the body. He was deaf in both ears and blind in the 
left eye. Excepting the right eye-lid every muscle of the 
face was paralyzed. Though he could not speak he was 
apparently conscious and observed everything that was 
going on about him. In addition to symptoms described 
Dr. Bremer found on examination that there was a complete 
loss of muscle-sense ; there were also anaesthesia and loss of 
pain-sense. Visual field contracted ; color-sense normal. 
No involvement of sphincters. The patient was secluded 
from relatives, cold douches applied to the thighs and 
abdomen, and electricity used. There being no benefit 
after a week's treatment arrangements were made to try 
hypnotism, and the patient was informed that he would be 
put to sleep by mysterious means and a cure would 
probably be effected. When entering the room to hypnotize 
him the patient stated that motion and sensation had re- 
turned. On examination sensation seemed perfect, but 
motor weakness was so great that patient could not walk, 
though he could lift legs freely. This improvement, how- 
ever, did not continue and the patient relapsed. Later, 
patient would become drowsy and pass into a profound 
sleep from which nothing could arouse him. At times 
these attacks were accompanied with opisthotonos or 
emprosthotonos. After having one of those attacks he 
would sometimes destroy the bed clothes and everything he 
could get hold of. During the attacks respiration and pulse 
were very much depressed. Once, during profound coma, 
his pulse was 20 and the respiration 1 per minute. At times 
the pulse would be 108 and then immediately drop to 30 
or 20. Temperature from 100 to 104.5. Patient left the 
hospital and went to his home, and about one month later 
suddenly completely recovered. The doctor makes some 
interesting comments upon the subject of hysteria in general. 
— {Alienist and Neurologist, Apr., 1892.) 



THERAPEUTICS. 



Case of Traumatic Tetanus Treated by the Tizzoni- 
Cattani Antitoxin. — A case of pronounced tetanus to 
which treatment by the tetanus antitoxin was successfully 
applied is reported by G. Casali. Patient, a woman, aged 
twenty-two, developed symptoms of the disease eight days 
after receiving an injury to her foot. The wound had quickly 



62 neurological. [Sept., 

become inflamed and inguinal glands were enlarged and 
painful. Progress of symptoms fairly rapid and when re- 
ceived into hospital fourteen days after injury jaws were 
tightly closed; speech was indistinct, slow and painful. There 
was marked "risus sardonicus", muscles of the neck and 
back were stiff and there was also some spasm of injured 
limb. Tizzoni confirmed the diagnosis and cauterized 
wound with silver nitrate, recommending daily ap- 
plication thereto of the caustic in one per cent, solu- 
tion. He also arranged that patient should receive two in- 
jections daily of 25 centigrammes of antitoxin, (prepared 
from the serum of an immunized dog) and ordered her to be 
kept well covered so as to favor sweating. After first injec- 
tion sweating was very profuse — as it was indeed after each 
of the first five injections. By evening the stiffness of the 
neck and tongue was markedly diminished. Five injections 
were given in like manner with similiar results, spasm 
gradually yielding and condition becoming steadily better. 
At this time there appeared a rise of temperature with a tem- 
porary recurrence of facial pain, but the tetanus proper had 
practically disappeared. Quinine and stimulants were then 
administered and a sixth and last injection of only 15 centi- 
grammes of antitoxin was made. This produced no sweat- 
ing and the patient, though cured of the tetanus, showed 
great restlessness and a slight vesicular rash appeared on 
chest and back. These untoward symptoms, due, it was 
thought, to septic absorption from the wound, cleared up un- 
der ordinary treatment and patient was shortly discharged 
with injured limb quite healed and no signs remaining of 
her illness save great weakness of limbs. Bacteriological 
examination of wound had revealed the presence in it of the 
tetanus bacillus, of streptococcus septicus and of a spore- 
bearing earth bacillus. It was to these latter organisms 
that the slight septic symptoms were attributed. — Brit. Med. 
Jour., July 9, 1892. 

B. M. CAPLES. 



Iodine Injections in Tetanus. — Dr. Sattas ( Gaz. desHop., 
Aug. 11, 1892) reports a case of tetanus successfully treated 
by iodine injections given hypodermically in ten centigram 
doses. These were without pain or untoward effects. 



J. G. KIERNAN. 



Duboisin in Hystero-Epilepsy. — Dr. Samueli reports the 
case of a girl of 20, who had as many as 23 attacks of 10 to 



1892.] THERAPEUTICS. 63 

12 minutes duration daily. The first sign was a closure of 
the eyes, followed by rapid breathing, a mimetic facial 
spasm and clonic spasm of the right arm and leg. The 
pulse was slowed, indicating irritation of the vagus. Con- 
sciousness was totally abolished. During the acme of a 
paroxysm Samueli injected 0.002 gm. duboisin sulphate. 
JMo further fits occurred. — ( Wien. Med. Wochenschr., No. 14, 
1892.) 



O. J. KAUMHEIMER. 



Untoward Effects of Pilocarpine in Epilepsy. — Dr. 
Fere states (Mercredi M&d., May 18, 1892) that the use of 
pilocarpine in epileptics whose attacks are under control 
may provoke an aggravated return of these. 



J. Q. KIERNAN. 



Prevention of Bromism by Intestinal Antisepsis. — Ch. 
Fere (Nouv. Iconogr. de la Salpdtriere, III) points out that 
small or moderate doses of the bromides are generally use- 
less in the treatment of epilepsy, and that daily doses of 10 
to 14 gm. are frequently needed. The phenomena of 
bromism, which are of frequent occurrence during the 
administration of such doses, can be prevented, according to 
Fere, by intestinal antisepsis. Naphthol in daily doses of 4 
gm., or salicylate of bismuth (2 gm. per day) are the most 
efficient and may be taken for a long time without detri- 
ment. — (Berl. Klin. Wochenschr., No. 12, 1892.) 



G. J. KAUMHEIMER. 



Metalotherapy in Hysteria. — Dr. Moricourt reports 
(Gaz. des Hop., April 2, 1892) a case of hysteria major with 
paraplegia, nervous crises, hallucinatory phenomena and ob- 
stinate vomiting, cured by the local application of gold. The 
patient was hypnotized. Copper, steel, lead, aluminum, 
gold and other metals were applied to regions anaesthetic in 
the waking state. Gold caused the most marked hyper- 
esthesia, whence its application. Moricourt calls attention to 
the intensity and complexity of the hysterical symptoms. 
Some of these had been present from birth. The gravest 
(vomiting, paraplegia, etc.) had appeared after her 
father's death. In childhood, convulsions followed by slight 
lingual paralysis and abundant epistaxis had occurred. 
Later there had appeared nervous crises, neuralgia, cardi- 
algia and gastralgia, as well as great sensibility to storms 
and hypochondriasis. There were also migraine, eye dis- 



64 neurological. [Sept., 

orders and tinnitus aurium, followed by anorexia, dyspepsia, 
pneumatoses, obstipation and vomiting. The patient was 
alternately amenorrheic and menorrhagic. Oppression, 
laryngeal spasms, nervous coughs and choreic movements 
from time to time occurred. There were alternate insomnia, 
lethargy, and prolonged slumbers with agreeable, but 
exhausting, and disagreeable dreams. There were quickness 
of temper, irritability and alternate fits of causeless laughter 
and tears. There was mental disorder with the usual 
hysteric hallucinations and somnambulism. There w T as 
incomplete paraplegia preventing walking but permitting 
movements of the limb in bed. There w T as absolute 
anaesthesia of the skin. The patient could not endure any 
odor but hyacinth, which put her to sleep. There were 
quotidian attacks of "hysteric fever" followed by convulsive 
phenomena, achromatopsia and verbal amnesia. Until gold 
was tried all treatment had proven useless. 

J. G. KIERNAN. 



Exalgine in Chorea. — Dr. Dana has an article in the 
Jour, of Nervous and Mental Diseases for July, in which he 
gives an account of his use of exalgine in sixteen cases of 
chorea. He believes that it has an unquestionably specific 
action in ordinary Sydenham's chorea. It is not indicated 
in chronic chorea, habit chorea, chorea major or convulsive 
tic. The dose used was two grains in capsules, three times 
first day, four times second, and five times third day, and 
finally three grains five times daily if necessary. At the 
same time he administered the citrate of iron and quinine. 
The effect of the drug should be watched carefully as it may 
cause muscular prostration, acute anaemia and cyanosis. In 
one of these cases the duration of the disease was seventeen 
days. In one other he had an almost equally rapid cure. 
In two, the trouble lasted but two weeks, and in one, four 
weeks. The average duration under the treatment was five 
weeks. Many of the cases had been under arsenical treat- 
ment without any result until the exalgine and iron were 
given. B> M.icAPiiEs. 

Solanine in Gastralgia is, according to Dr. Desnos, 
( Bull, gen de Therap., June 30, 1892) of benefit in five to ten 
centigram doses daily. j. G . kibbnan. 

Thymacetine. — Jolly (Berl. Klin. Wochenschr., No. 14, 
1892) reports on trials made in the nervous and psychiatric 



1892.] THERAPEUTICS. 65 

clinic at Berlin with thymacetin, a derivative of thymol, 
analogous to phenacetine. It is a white, crystalline powder, 
slightly soluble in water. Doses of 2 gin. were not poisonous 
to dogs. Its antithermic action was not investigated. The 
doses given ranged from 0.2 gm. to 1 gm. In 7 cases of 
hemicrania the pain was moderated, although the inci- 
dental effects were such that the patients declined to take 
the drug again. In a number of cases of habitual head- 
ache and neuralgic pains the action was similar to that of 
phenacetine, rapid and certain in some cases, slight or 
absent in others. In headache due to organic brain lesion 
no relief was reported by one patient; decided relief 
repeatedly by another. In a tabetic with severe gastric 
crises, who also received morphine, transient relief was 
obtained, although the morphine could not be abandoned. 
In morphinists with pains in the extremities during the 
period of withdrawal, the remedy was useless. A number 
of the patients complained of a rush of blood to the head 
soon after taking the remedy. In these cases a moderate 
acceleration of the pulse was observed. Several male 
patients complained of various disagreeable sensations in 
the urethra, although the urine was normal. Several 
patients after taking 0.5 gm. became so sleepy as to sleep 
soundly several hours during the day. This led to a trial 
of its powers as a hypnotic if given at night in doses of 0.5 
to 1 gm. 26 patients, partly delirious, partly noisy paretics, 
received it. In 10 cases no result was observed. In the 
remainder a fair amount of sleep was obtained and in a 
few, sound sleep. The slumber was not as deep as that 
which follows chloral in doses of 2 gm. 

G. J. KAUMHEIMER. 

On Salipyrin. — Reports on the therapeutic value of this 
combination of antipyrin and salicylic acid are conflicting. 
Argo Therap. (Monatsh., No. 5, 1892, Wien. Med. Blaett., No. 
22, 1892) reports almost invariable success in asylum prac- 
tice. He gave it in doses of 1 gm., 3 times daily. In several 
cases of severe hemicrania complete relief was obtained in 
from 10 to 15 minutes. Similar results were observed in 
post-alcoholic headache, in which antipyrin had been use- 
less. In one case a distinct hypnotic effect was observed 
after a dose of 1 gm. Several cases of chronic rheumatism 
were relieved at once. It is best given dry upon the tongue 
followed by a glass of water. Per contra, Hitchmann ( Witn. 
Med. Blaett. No. 17, 1892) has seen no such marvelous re- 



66 NEUROLOGICAL. [Sept., 

suits. As an anti-rheumatic it is no better than the soda 
salt of salycilic acid. Its most marked action, according to 
H., is as an antineuralgic. In 2 cases of chronic myelitis with 
lancinating pains, complete relief was obtained by daily 
-doses of 0.5 gm. each. In 2 others, a numbness took place 
of the pain. Habituation occurred on the ninth day so that 
the dose had to be increased. In quite a number of other 
painful affections, such as lumbago, headaches, and neural- 
gias, relief was obtained by doses of 3 to 6 gm. per day. 
Large doses are likely to produce headache, nausea and 
heartburn. Sweating was often exhausting and profuse. 
He concludes that "salipyrin is an innocuous remedy, useful 
in many cases, but, on the whole, very unreliable." 

G. J. KAUMHEIMER. 

Chloralamid ; Its Action Based upon a Study of 280 
Cases. — By Dr. James Wood. — In ordinary cases the doctor 
.-states that this remedy stimulates the respiratory centre, the 
blood pressure remaining uninfluenced. It is especially 
useful in insomnia with the high arterial tension of Bright's 
disease. Its stimulating effect upon respiration would indicate 
its use in the night-sweats of phthisis. We quote the follow- 
ing from the doctor's article : "When the drug is given for 
its hypnotic effect its physiological action is noticed in from 
tthirty to ninety minutes, and the sleep induced 
lasts from five to nine hours, is natural and refresh- 
ing and not followed by any unpleasant sequelae. No 
--symptoms of cerebral congestion or any unpleasant sensa- 
tion in the head or other parts of the body are experienced. 
No evil effects followed the continued use of the drug for 
ten days, and during this time it was not necessary to 
increase the dose, nor was its hypnotic effect diminished. 
Any psychological influences can therefore be eliminated. 
There is no cumulative action of the drug, nor are there 
any cases on record where a habit has been formed. The 
best time for administering the drug is just before retiring. 
It can be given in capsule, dry on the tongue, as an enema, 
or preferably in solution. As palatable a combination as 
'One could wish is the following, which will be found useful 
in private practice. It is a pleasant mixture with a slightly 
-acid taste : 

^ Chloralamid 3ij 

Tr. Cardamom. Co. li 

Misce bene et adde 
Syr. Aurantii. 

Syr. Rubi . Idaei a& 5ss 

JM. et Sq. : From One-half (%) to one tablespoonful repeated. 



1892.] THERAPEUTICS. 67 

The dose which yields the best result is from thirty 
to forty-five grains. Not more than one hundred 
grains should be given in twenty-four hours. The conclu- 
sions, based upon its use in two hundred and eighty cases, 
are briefly as follows : That it is a most useful hypnotic, 
reliable, safe and pleasant. That it has a place as an 
anhidrotic in phthisis. That it is superior to other drugs 
because in hypnotic doses it stimulates respiration, and but 
slightly, if at all, influences pulse, temperature, or urinary 
secretion. That no collateral symptoms of any consequence 
exist. That the best hypnotic dose for an adult is forty 
grains. That it is given preferably in an alcoholic solution 
just before retiring." — [Brooklyn Med. Jour., Apr., 1892.) 

(In a case in the Milwaukee Sanitarium where other hyp- 
notics failed, ten-grain doses of chloralamid produced a 
sound and refreshing sleep. In this case sulphonal pro- 
duced irritation of the stomach and bowels, and was also 
followed by depression and irritability. Chloralamid had 
no such effects.) 



Chloralamid in Insomnia. — Dr. Collins concludes an 
article on chloralamid as follows : "Without entering into 
details in respect to each case treated, it seems that the fol- 
lowing conclusions can be drawn: 1. Chloralamid is a 
safe and one of the most reliable hypnotics. 2. It is not 
ordinarily followed by distressing after-symptoms, partic- 
ularly headache. 3. It is especially valuable as an hyp- 
notic where pain is a prominent factor, but not violent. 4. 
In cases of insomnia where there is excessive activity of 
the brain it is also useful. 5. On account of its stimulat- 
ing activity upon the respiratory function it is the hypnotic 
par excellence in nervous exhaustion associated with an 
asthenic condition of respiration and symptom complex 
indirectly dependent upon this, brought about by defective 
oxidation and the formation of unstable chemical compounds 
in the system. 6. On account of its very slight action in 
depressing the circulation it, can be given in diseases 
associated with a weak heart with greater safety than most 
of the other hypnotics, not excepting chloral itself. 7. 
It is conveniently administered in the shape of an elixir, 
and this overcomes the need of dissolving it. 8. Its dose 
is from one to three scruples, administered one hour before 
sleep is desired, and this should not be repeated within two 



68 neurological. [Sept., 

hours, for occasionally the action of the drug is delayed." — 
(Jour, of Nervous and Mental Diseases, July, 1892. ) 



Piperazine: Uric Acid Solvent. — A recent communi- 
cation on piperazine, by Dr. Biesenthal in the Berlin 
Klinishe Wochenschrift, contains a very favorable report on this 
remedy, from which the following information is gleaned. 
The non-corrosive and non-poisonous action of the strong 
base is remarked, and confirmatory evidence given, not 
only of the extraordinary solvent action of piperazine on 
uric acid, but also of its capability of dissolving the 
organic cementing substances that bind the uric acid con- 
crements together. On internal administration piperazine, 
which is not decomposed in the human system, first sat- 
urates the uric acid still dissolved in the organism, and the 
remainder, dissolved in the alkaline blood, attacks any de- 
posits of uric acid, dissolving both acid and cement, and 
carrying the former out of the system in the form of the 
easily soluble neutral urate of piperazine. As a result of 
the solvent action of piperazine upon the organic cementing 
material of concrements, it has occurred many times in the 
experience of Dr. Biesenthal that concrements composed 
almost entirely of calcium phosphate and uric acid were 
disintegrated by this remedy. The piperazine dissolved 
the combining material that held together the particles of 
calcium salt and consequently loosened the whole mass so 
that the concrement became friable and readily broken up. 
On account of this property of piperazine, attacking and 
disintegrating concrements composed largely of phosphate 
of lime, it is further a special advantage that the base does 
not communicate an alkaline character to the urine, as by 
its use there is no danger of the formation of deposits of 
phosphates. For the same reason the combined treatment 
of sufferers from uric acid diathesis with such large doses 
of alkaline carbonates, as for instance administered in 
Vichy, Eau de Vals or Wiesbaden gout water, is extremely 
questionable, and may produce more harm than good. The 
formation of vesical stones from urine containing much 
phosphate of lime in solution at the temperature of the 
body, must be enormously increased by the regular admin- 
istration of large quantities of strongly alkaline mineral 
water, since the phosphoric acid will be neutralized and the 
phosphate of lime precipitated, giving rise to fresh deposits 



1892.] THERAPEUTICS. 69 

of vesical calculi. The continuance of the mineral water 
treatment frequently accounts, it is thought, for the differ- 
ence in chemical composition between the renal and vesical 
calculi, the former generally consisting principally of urates, 
the latter of phosphates and oxalates. This theory finds 
confirmation in the examination of many urinary concre- 
ments, a very instructive specimen of which was recently 
described by Dr. Israel as consisting of a small uric acid 
nucleus, around which phosphate of lime had accumulated 
to form a mass of considerable proportions. The patient 
from whom it was removed had partaken of the Obersalz 
spring for a considerable time, which contains considerable 
quantities of alkaline carbonates. Thus the physician 
should consider the danger of the alkaline treatment, and 
at least limit the use of alkaline waters and combine the 
piperazine treatment. 

Pilocarpine and the Leucocytes. — Dr. Maurel (Bull, 
gen. de Iherap., April 15, 1892) finds that ten centigrams of 
pilocarpine chloro-hydrate suffice to kill the leucocytes of one 
hundred grams human blood. With five centigrams they 
live but a few hours and from the instant of contact they 
are sensibly modified. The mixture of atropine-poisoned 
and pilocarpine-poisoned leucocytes in due proportions re- 
sults in the revival of both. 

J. G. KIERNAN. 

Atropine and the Leucocytes. — Dr. Maurel (Bull. gen. de 
Therap., April 15, 1892) concludes that atropine in five 
centigram doses, or even less, kills instantly all the leucocytes 
contained in one hundred grams human blood. With two 
centigram doses the leucocytes live but a few hours, and 
from the moment of contact they present modifications of 
their activity and mode of displacement. In the rabbit the 
leucocytes can live in solutions containing even more than 
two centigrams. Taking into account this and the preced- 
ent facts, Maurel is of opinion that the leucocytes intervene 
in death by atropine and its antecedent phenomena. 

J. G. KIERNAN. 

Strychnine and the Leucocytes. — Dr. Maurel (Bull, 
gen. de Iherap., March 30, 1892) concludes that five cen- 
tigrams strychnine sulphate suffice to kill suddenly all the 
leucocytes of 500 grams human blood ; two centigrams of 
strychnine sulphate kill the same quantity in a few hours. 



70 NEUROLOGICAL. [Sept., 

At 86° to 95° the same dose causes the leucocytes to assume 
the spherical shape, but they return to their ordinary shape 
at a temperature of 98.6° to 100°. In such a dose, and even 
at these last temperatures, not only is leucocyte life short- 
ened, but their activity is so diminished that it is evident 
that a much more minute quantity must have a decided 
action upon these leucocytes. In strychnine poisoning leuco- 
cyte death and death of the organism are simultaneous. 
Experiments upon decapitated animals show that leucocytes 
survive the death of the animal. Maurel has found that 
neither curare nor potassium cyanide kill the leucocytes 
simultaneously with the animal, whence he concludes that 
leucocyte death is not necessarily an, immediate result of 
the death of the animal. Whence it results that simulta- 
neous death by strychnine is evidence of the immediate 
action of the alkaloid upon the leucocytes. The red blood 
corpuscles evince, even in doses of ten centigrams of strych- 
nine sulphate to one hundred grams of blood, no special 
results. They preserve their haemoglobin even after 
leucocyte death. Strychnine, even in ten centigram doses, 
does not cause fibrin deposit. Maurel is of opinion, from 
the effects of strychnine upon the leucocytes, that they play a 
part in strychnine poisoning. 

J. G. KIERNAN. 



Multiple Neuritis. — Dr. C. K. Mills, of Philadelphia, 
has published a lecture dealing with this condition and its 
complications. Notes of several cases are given, some mild, 
some severe, one complicated with acute rheumatism, 
another with posterior sclerosis, and another with a cerebral 
lesion causing, apparently, a slight condition of right 
hemiplegia. Dr. Mills insists upon absolute rest as a pre- 
liminary and emphasises the importance of gentle care 
in nursing patients suffering from neuritis, on account of 
the excessive pain which handling and movement produce. 
He is not in favor of half measures in regard to stoppage of 
alcohol, which is in most cases the toxic agent, and, except 
in the case of a few broken down old topers, he thinks it 
should be withdrawn at once and entirely, while the great- 
est care should be given to careful and abundant feeding. 
In a few sthenic cases he is inclined to advocate bloodletting, 
especially should there be any signs of congestion or inflam- 
mation of the spinal cord. For the relief of pain, hot appli- 
cations, frequently resorted to, and opium, best given hypo- 



1892.] THERAPEUTICS. 71 

dermically, may be necessary. As recuperative agents, 
strychnia by the mouth or hypodermically is recom- 
mended, as well as cinchona and digitalis, while 
such foods as milk and beef extracts will tend to have 
a similar effect. In the early stages, salicylic acid or salicy- 
late of soda, saiol, or oil of gualtheria are recommended as 
anodynes which are especially useful if there is a rheumatic 
condition present, while cerebral symptoms are best 
counteracted by the bromides, antipyrin or acetanilide. 
Baths, simple or electrical, are also useful, but extreme care 
is necessary in giving them lest the patient should be in 
any way exposed to the danger — a very great one in these 
cases — of cold. Massage and passive or active movements 
can only do good when the stage of acuteness and excessive 
pain is passed, and the same is true of electricity in what- 
ever form it may be found desirable to give it. The use of 
some anodyne ointment for massage is also recommended. 
Even with these numerous means of combating the con- 
dition great patience and long-continued treatment are 
necessary if success be attained. — (Lancet, April 30, 1892.) 

B. M. CAPLES. 

Paralytic Obstruction of the Intestine Relieved by 
the Constant Current. — Semmola has reported the case of a 
man, twenty years old, and of nervous temperament, in whom, 
after the occurrence of diarrhoea, symptoms of intestinal 
obstruction appeared; to these ischuria was added. Ordinary 
treatment was without avail and cceliotomy was proposed. 
From the suddenness of onset of symptoms of obstruction 
after the occurrence of diarrhoea, from the paroxysmal char- 
acter of the pain, from the coexistence of paralysis of the 
bladder without previous disease, and from the neuropathic 
tendency of the patient, a diagnosis of paralysis of the 
bowel was made, and the application of constant current 
recommended. The positive pole attached to a catheter was 
introduced into rectum, and negative pole stroked upon the 
abdomen along course of colon. Applications were made for 
from eight to ten minutes thrice daily. Symptoms gradually 
improved and after ninth application bowels were spon- 
taneously moved. In the course of ten days patient was 
completely restored to health. — (Med. News, July 2, 1892.) 

B. X. CAPLES. 

On an Observation in Cephalalgia. — Dr. H. Weiss has 
found, as has every other physician, that in migraine and 



72 neurological. [Sept., 

severe headaches every possible drug or procedure is 
occasionally useful, but more often useless. He accidentally 
discovered that on exerting pressure in the median line of 
the abdomen, midway between the ensiform cartilage and 
umbilicus,, the headache, tenderness of the scalp and photo- 
phobia vanished like magic At first he did not know 
what to make of his discovery, but soon found that the 
beneficial effect was the result of compression of the aorta, 
and not of the sympathetic, as he had surmised. The effect, 
however, is transient, the symptoms returning sooner or 
later, but these patients are grateful for the slightest relief. 
He has tried it successfully in 23 female patients of varying 
intelligence and size. He supposes that it acts by changing 
the distribution of the blood and presents the "discovery" 
for what it may be worth, making no claims. — (Prag. Med. 
Woch&isch., No. 15, 1892.) 

G. J. KAUMHEEtfER. 

Some remarks recently made by Dr. Graily Hewitt in the 
British Medical Journal, as to visual disturbances causing sea- 
sickness, and the remedial measures indicated — the main- 
tenance of a horizontal position and bandaging the eyes — 
have called forth a rejoinder from Professor Charteris, of 
Glasgow, who will be remembered as advocating the use of 
a solution of chloralamide to combat the mal de mer. In the 
first instance he points out that blind persons become sea- 
sick, and persons sleeping are not always protected from an 
attack, whilst for obvious reasons the agencies suggested 
could only be used during a short voyage. Professor Char- 
teris, therefore, without denying that the above precautions 
might tend to ward off an attack, again draws attention to 
the mode of treatment already advocated by himself and 
employed very advantageously in long voyages. A solution 
containing in each ounce 30 grains of bromide of potassium 
and 30 grains of chloralamide would, he maintains, be also 
equally effective as a preventive of sea-sickness in short 
journeys by sea, and cites a number of recent personal ex- 
periences and trials with fellow-passengers in support of his 
view. The intending passenger should prepare for the 
journey by taking an antibilious pill for two successive 
nights before going on board, and when on board should 
take no food, retire to his cabin and take a full dose of the 
solution. The effects of this treatment have produced the 
greatest satisfaction whenever adopted, the patients sleeping 



1892.] THERAPEUTICS. 73 

soundly, maintaining a good appetite, and even, it is 
averred, positively enjoying the rolling rnotion of the 
steamer, whilst in cases in which vomiting had already 
commenced before administration the retching was imme- 
diately relieved. Professor Charteris, therefore, confidently 
recommends this solution as absolutely safe and harmless, 
producing a refreshing sleep without any baneful after 
effects, and when judiciously administered preventing, and 
in all cases alleviating, sea-sickness. — (Notes on Neiv Remedies, 
July, 1892.) 



SURGERY AND TRAUMATIC NEUROSES. 



Cerebral Tumor Removed Twice in the same Patient. 
— Erb reports the following case: Man, aged forty-seven, 
had clonic convulsions affecting the left arm and leg and 
left side of the face. This condition was followed after a 
time by hemiparesis of the whole of the left side. Trephin- 
ing was performed and a gliosarcoma was found in the 
right anterior central convolution ; this was removed as 
completely as possible. Operation was followed by marked 
improvement of paretic symptoms while the convulsive 
phenomena ceased altogether. Eight months later, how- 
ever, they came on again, though with less severity. A 
year after first operation patient was again trephined and it 
was found that recurrence had taken place. The growth 
was again extirpated, the circumjacent tissue being removed 
even more freely than before. Second operation was fol- 
lowed by improvement, but the symptoms did not entirely 
disappear. — (Brit. Med. Jour., July 9, 1892.) 

B. M. CAPLES. 

Abscess of the Brain : Trephining : Recovery. — Dr. 
Morrison reports a case in the Med. Progress of August. 
Patient received cut through left side of scalp, parallel with 
Rolandic line and one inch in front of it. On afternoon of 
eighth day patient began to lose power in right arm and 
leg so that she had to be assisted in and out of bed. When 
author saw her she was in a semi-stupid condition with no 
delirium and no convulsive movements. Complete paraly- 
sis of right arm and leg, right side of face and tongue, and 
thick, indistinct speech. Periosteum was found separated 
from bone for three-fourths of an inch on each side of the 



74 neurological. [Sept., 

wound in skull. No pus present. Skull trephined in front of 
middle of bone injured; it was found that internal plate had 
been separated from external plate one-half inch on each side 
of cut. Entire seat of fracture was removed with rongeur 
forceps, leaving an opening one and one-half inches in 
length by one inch in width. The dura protruded into 
wound and slight pulsation was observable. Trie membrane 
was covered with inflammatory exude in which were im- 
bedded fragments of the internal plate. At upper part of 
opening was a small, dark, extra-dural blood clot about f of 
an inch in diameter. No sign of suppuration external to 
the dura. One of the fragments penetrated the dura, and 
in drawing it away an opening was made through which 
escaped about one fluid ounce of yellowish-green pus. 
Cavity of the abscess was found to be one and one-half inches 
in depth. Carefully washed out with plain boiled water 
and a rubber drainage tube inserted. Flap was then re- 
placed and secured with silk sutures and dressed. Patient 
continued steadily to improve. Mental condition is normal 
and she is now practically well. — (Med. Progress, Aug., 1892.) 

B. M. CAPITES. 



When Shall we Trephine in Fractures of the Skull ? — 
This is the title of an article by Dr. Lanphear of Kansas 
City, in which he reviews the earlier rules laid down for 
trephining and summarizes his conclusions as follows: 

RULES FOR TREPHINING IN INJURY OF THE SKULL. 

1. In every case of localized injury to the head where 
unconsciousness persists for more than an hour, exploratory 
operation, including opening the skull if necessary, should 
be done. 

2. The appearance of stupor some hours after a head 
injury indicates meningeal haemorrhage and requires tre- 
phining at the point of injury if known, or at point indicated 
by cerebral localization; the middle meningeal being the 
usual source of trouble. 

3. Even in very extensive injury to the head, operation 
should be made, since removal of debris, restoration of normal 
contour and cleaning of injured tissues can add but little to 
the danger and may save life. 

4. In every case of doubt exploratory operation is justi- 
fiable. 



1892.] SURGERY AND TRAUMATIC NEUROSES. 75 

5. Compound fractures, with or without apparent de- 
pression, demand enlargement of the wound and careful 
exploration. 

6. All cases of depressed fracture, either simple or com- 
pound, require trephining and elevation, whether there be 
pressure symptoms or not. 

7. All punctured fractures and gun-shot wounds im- 
peratively indicate the use of the trephine. 

8. In simple fracture of the skull where any symptoms 
of brain trouble persist, exploratory operation should be done. 

9. In all cases of local injury to the skull, whether 
fracture or bruise, followed by evidence of inflammation of 
bone or persistent symptoms of brain irritation, or of pus 
between the bone and dura, the trephine should be re- 
sorted to. 

Gun-Shot Wounds of the Cerebrum. — Dr. Ruth reported 
the above case before the Amer. Med. Ass'n. He said that 
the line pursued by the ball through the brain was usually 
a straight line, but that it did not bear any definite rela- 
tion to direction from which the shot was fired, and 
after passing through brain it seldom rebounds sufficiently 
to re-enter the brain to any extent. In searching for track 
of ball he uses a probe with a hemispherical porcelain tip 
and a slender aluminum shaft. A trephine not less than 
three-fourths of an inch in diameter should be used. He 
made the following summary: 1. A ball can be followed 
in its course through the brain. 2. Having been followed 
to the point of impact on the opposite side of the skull, a 
trephine disk should be removed, drainage established and 
ball removed if possible. 3. That the probe is best which 
gives the greatest resistance to penetration with the least 
possible lateral friction on its shaft by the collapsed canal. 
4. That hemispherical-front porcelain tip and aluminum 
shaft answer the indications for lead detection required in a 
probe better than anything else. 5. That one intending 
to follow balls through the brain should thoroughly famil- 
iarize himself with the resistance the normal brain offers to 
penetration by the probe he expects to use, so that he may 
know when he is applying force within safe limits. 6. 
That he should frequently grasp and remove balls and 
pieces of bone with the forceps of his choice on the cadaver 
Before attempting it upon the living subject. — (Med. Record, 
July 2, 1892.) B . M . CAPLES . 



76 neurological. [Sept., 

Epileptiform Convulsions Following Head Injury; 
Trephining ; Recovery. — Dr. Whipple reports the case of a 
seaman, aged sixty-three, who fell down the hold of a ship, 
cutting his head and breaking his right leg. Was uncon- 
scious for eighteen hours. After consciousness returned 
suffered from headache for some days. Four days after 
accident had a fit, since which time he had been subject to 
fits, having as many as five or six a week. On right side of 
scalp was a concentric shaped scar crossing fissure of Rolando 
three-quarters of an inch from the sagittal suture. Pressure 
over this region gave pain. No depression could be felt ; 
had no paralysis. Pulse became very feeble after a severe 
fit and occasionally he would be quite collapsed. Breathing 
at times Cheyne-Stokes. The author removed with a 
conical-shaped trephine a piece of bone beneath the scar the 
size of a shilling. Bone was very thick ; dura mater firmly 
adherent. Patient was very restless and troubled with sick- 
ness after operation. Remained in about this condition for 
a w r eek, at the end of which time began to improve and in 
two weeks from the time of operation was allowed to get up. 
Made an uninterrupted recovery, having had no fits since 
operation. Now able to walk about and takes his food welL 
—{Lancet, Apr. 16, 1892.) 

B. M. CAPLES. 



Craniectomy for Double Optic Neuritis With Mi- 
crocephaly, by Dr. Miller. Patient was a boy eight months 
old, microcephalic and exhibiting double optic neuritis. 
Spine and limbs almost constantly extended and rigid ; 
thumbs strongly adducted and fingers flexed over them ; 
legs tightly adducted, right being crossed in front of left. 
Marked nystagmus and convergent squint, and eyeballs were 
deeply drawn into the orbits giving child an aged and 
pained expression. Ophthalmoscopically there appeared 
severe optic neuritis and atrophy in both eyes with some 
patches of choroidal pigment in right. When legs 
happened not to be firmly extended knee-jerk was readily pro- 
duced. All cranial sutures were completely ossified, no 
traces of fontanelle being detected. Mother said that there 
were no soft spots on the head at birth. The coronal edge 
of the frontal bone was thick and raised above the parietals ; 
left parietal bone distinctly flatter than right; all bony 
eminences on cranium slightly marked ; forehead receding. 
Linear craniectomy was performed. Length of the bony 



1892.] SURGERY AND TRAUMATIC NEUROSES. 77 

excision was a little over three inches, beginning in front 
at the inner side of the left frontal eminence and extending 
backward parallel to sagittal suture. The opening w 7 as 
one-half inch wide, and from each end of its outer edge a 
short branch cut was made with gouge forceps so as to 
leave the outer boundary of the bone wound in the form of 
a projecting flap unsupported at its two ends, thus allowing 
of some subsequent eversion by the brain pressure. The 
child made an uneventful recovery. The spastic condition 
of the limbs diminished from the time of the operation. 
The nystagmus and squint disappeared, eyeballs came for- 
ward in the orbits and patient assumed the natural expression 
of a baby. A few days later child was able to stand. Vision 
improved. Intelligence had so increased that the patient 
laughed like any other baby when played with and talked 
to. When last seen intellectual activity was increased; 
general health excellent. — (Brit. Med. Jour., July 23, 1892.) 

B. M. CAPLES. 



Neurectomy of the Popliteal Sciatic Nerve for Pain- 
ful Neuroma, the Result of Gun-Shot Injury. — Dr. 
Ricketts reports the following case : Man, aged twenty- 
seven; shot two years previously; suffered excruciatingly 
ever since. By advice of physicians he became a morphine 
taker. Reached the maximum of fifteen grains daily, 
hypodermically. Examination showed that the ball had 
passed obliquely through the left leg to the inner side, three 
or four inches above the condyle anterior to the hamstring 
of biceps, passing upward at an angle of forty-five degrees 
and coming out about middle of thigh externally. Patient 
stated that when shot he had the sensation in his toes and 
not at the real site of the injury; was surprised to find it 
higher up in the leg. Within an hour after injury pain 
was equally distributed over foot and leg below the knee. 
At the operation the nerve was found to be enlarged to 
three times its normal size for a distance of 1J inches, and 
divided much higher up in this case than usual. This was 
fortunate, for had it been normal both branches would have 
been divided. The internal branch was found to be the in- 
jured one and the external was seen to be adherent to it for 
about three inches. A section was made If inches long, 
including the entire enlargement. Leg was flexed when the 
section was made and was retained in this position by means 
of straps. Pain gradually subsided. Morphine was withdrawn 



78 neurological. [Sept., 

and small doses of bromide and chloral were substituted. 
After the 12th day patient was allowed to be up and around on 
crutches. Left hospital on 22nd day. Author heard from him 
recently and finds that he is free from pain and the morphine 
habit— (Med. Record, July 2, 1892.) 

B. M. CAPLES. 



Neuralgia, of the Fifth Nerve Relieved by Divid- 
ing and Twisting. — Dr. Wyeth presented a patient before 
the New York Surg. Soc, who came under his care for 
trifacial neuralgia, the pain being most severe in the infe- 
rior dental branch of the fifth nerve. Had suffered for 
five years. Speaker had operated in July, exposing all 
three branches of the trifacial, which he had cut and then 
twisted in order to destroy the conductivity of the fibers. 
This seemed better than opening the skull and dividing the 
Gasserian ganglion. Patient was relieved at once and there 
had been no recurrence of pain. There was loss of sensa- 
tion. In another case that he had treated, in which the 
third division of the nerve had been resected unsuccess- 
fully, he had cut all the divisions of the nerve and twisted 
them and patient had remained free from pain. Dr. Lange 
had operated in a case of severe neuralgia of the third 
branch of the fifth nerve in which epileptic convulsions 
were caused by the pain. He operated by Kronlein's 
method, seizing the nerve below the foramen and twisting 
it slowly until it ruptured. The two main branches of this 
nerve, lingual and inferior dental, were separated, and sec- 
tions of nerve tissue from an inch and a half to an inch 
and three-quarters in length were removed, while four or 
five inches of the muscular branches were excised. The 
patient made a good recovery and had remained free from 
the fits for three months after the operation. — (N. Y. Med. 
Jour., July 2.) 



B. M. CAPLES. 



Treatment of Spina Bifida by Excision. — Dr. Powers 
reports a case in which the lumbar meningeal sac was suc- 
cessfully removed. The patient was a poorly-nourished, 
rather undersized man, thirty-five years of age ; was afflicted 
at birth with a spina bifida. Daring past year weakness 
has involved the arms. Some difficulty in raising food to 
his mouth. Right upper extremity affected to a greater 
extent than left. At times a cold sensation crosses the chest 
from shoulder to shoulder. Has had diplopia at a distance 



1892.] SURGERY AND TRAUMATIC NEUROSES. 79 

during past year and one-half. Examination of the eyes 
reveals in right, veins of fundus dilated ; in left, optic nerves 
of a whitish, atrophied appearance ; pupils small ; not im- 
mobile. Walk is ataxic and paraplegic ; arms very ataxic. 
Sensation to touch much impaired below nipple line; re- 
flexes abolished. There was a flattened tumor a little to right 
of median line opposite last lumbar vertebra. Tumor was 
removed, sac ligated and wound closed. Complete primary 
union followed. Author sums case as follows : a A con- 
genital spina bifida with small tumor which gave little 
trouble in childhood. No nervous element until fifteen 
years of age, then slight interference with locomotion. At 
twenty-eight years development of a progressive ataxia and 
paretic state possibly due to continuous irritation of the 
tumor by clothing about waist. Successful and simple re- 
moval of tumor, a source of comfort to patient, and fol- 
lowed by improvement in ataxic symptoms, which im- 
provement may or may not have been due to this removal 
(and which seems to have been temporary)". On further 
investigation the author concludes that treatment by excis- 
ion must certainly be thought the most rational and most 
scientific. Improvement will follow more careful selection 
of cases, the choice of an appropriate time for operation, and 
added knowledge in technique. The results thus far ob- 
tained are certainly encouraging and lead to the belief that 
the operation is one which will find added favor in the 
future. — (Med. Record, July 16, 1892.) B . Mi caples. 



Substitution of Defects in Nerve Trunks. — Gluck 
proposed, several years ago, to insert strands of catgut 
or silk in the course of nerves (or tendons) which present an 
otherwise irreparable solution of continuity. He recently 
exhibited a number of these cases to the Berl. Medic. 
Gesellsch. The functional results were very good. Bern- 
hardt stated that he had treated some of these cases elec- 
trically. In one, 5 cm. of the radial nerve had been lost. 
Immediately after the operation, R. D. was almost complete. 
Only after a year's treatment voluntary motion was pos- 
sible. Five years later, although active mobility was good, 
a quantitive reduction, of electric excitability still existed. 
Other cases were of similar duration. Bernhardt states 
that even if union is complete, we may have to wait a year 
or more for the return of active motion. — (Deutsche Med. 
Wochensch., No. 18, 1892.) G . Jm kaumheimer. 



80 w NEUROLOGICAL. [Sept., 

Operation for Pressure Paralysis. — Dr. Urban, of 
Liepsic, spoke before the Congress of the German Surgical 
Society of Berlin concerning operative procedures necessi- 
tated on account of the pressure of the spinal column 
against the cord. At the injured point a horizontal incision 
is made through the skin and soft parts until the column is 
reached ; another incision is also made on the other side, 
parallel with the latter, and some distance beyond the 
injured part. Spinal column then chiseled out until upper 
half with skin and muscles lying above it can be raised 
upward and spinal cord can be laid bare. The part which 
has compressed the cord is now raised with a chisel or some 
similar instrument, and the parts are again turned back and 
allowed to heal. In one of Prof. Thiersch's cases the opera- 
tion was followed with success. — (Med. Record, July 16, 1892.) 

B. M, CAPLES. 

Neurotomy of the Sympathetic in Epilepsy. — Dr. 
Rudolph Jaksch attempts to obtain a rational explanation 
of the undoubted success following ligature of the vertebral 
artery in some cases. He rejects the theory that the inter- 
ruption of the circulation in the artery has any influence 
in the matter, and attributes the good results to division of 
the vertebral plexus of sympathetic nerve fibers. This 
plexus has been denominated by Hyrtl "the deep cervical 
portion of the sympathetic system". He assumes that in 
all cases in which the operation resulted beneficially, the 
epilepsy was caused by some peripheral irritation which 
was conducted centripetally by the sympathetic. As the 
irritation may travel by the superficial as well as by the 
deep portion of the sympathetic, he recommends that when 
the vertebral artery is tied that the superficial plexus be 
excised at the same time. This can be done through the 
same incision, the section being made above the last cer- 
vical ganglion, as the plexus lies on the deep cervical 
muscles. He relates two cases. The first was a soldier, 
aged 23. He had had repeated convulsions at the age of 
4. After that he was healthy up to his twentieth year. 
Convulsions then set in, at first at intervals of eight to ten 
weeks, at last as often as three to eight times daily. An in- 
tense pressing pain in the epigastrium, frequently accom- 
panied by vomiting, immediately preceded the convulsion. 
Bromides having no effect, Jaksch tied the right vertebral 
artery, and at the same time cut the superficial plexus and 



1892.] SURGERY AND TRAUMATIC NEUROSES. 81 

turned its upper end up to prevent reunion. The next 
morning patient on awakening said he felt as if he had had 
a convulsion during sleep. Up to the time of writing, over 
a year after, he had had no more convulsions. Case II was 
also a soldier, aged 22. His first convulsion occurred after 
a severe enteritis, two years before. One or two nocturnal 
convulsions occurred every month, preceded b} r headache, 
nausea and an unpleasant indescribable feeling in the 
abdomen. A similar operation to that performed in the 
first case was followed by a like result, the patient report- 
ing, eight months afterward, that he had had no more fits. 
—(Wien. Med. Wochensch., No. 16-17, 1892.) 

G. 3. KAUMHEIMER. 



The Operative Treatment of Epilepsy. — Dr. Herman 
Kuemmel gives his experience with the various operations 
suggested for the relief of epilepsy. Trepanation, according 
to Broca and v. Bergmann, is one of the oldest of operations. 
Dr. Kuemmel first considers ligation of the vertebral ar- 
teries. This operation was first performed by Alexander, of 
Liverpool, at the suggestion of Hughlings Jackson. In a 
communication Alexander stated that he had operated 35 
times, with 8 permanent cures; 11 cases considerably im- 
proved; 16 cases not improved and 3 deaths (haemorrhage, 
embolism and pleurisy, each one case). Bernays, Sydney 
Jones and v. Baracz have also reported cases without per- 
manent results. Kuemmel has performed the operation 
twice. Case 1 was that of a boy of 16 whose epilepsy began 
at the age of 7. Frequent and violent convulsions occurred 
and stupor to a considerable degree was present. The left 
artery was tied first, without affecting the convulsions, fol- 
lowed in a month by the right. The attacks became milder 
and less violent, the intellect brighter, but the improvement 
was of short duration. The epileptic paroxysms again 
became frequent and violent and the temper very irritable, so 
as to render his transfer to an asylum necessary. There his 
mental faculties decayed more and more. In case II, a 
man aged 25, with a duration of 4 years, the history after 
operation was almost identical with case I. The curative 
effect of this operation was supposed to be due to the sever- 
ing of the fibers which arise from the superior cervical 
ganglion and accompany the artery to the brain. Its 
author, endeavoring to attain the same end in another way, 
lias suggested and accomplished the removal of the superior 



82 neurological. [Sept., 

cervical ganglion. Kuemmel has performed this operation 
once upon case III, a woman aged 46 years, who had been 
subject to epilepsy 15 years. The attacks occurred at vari- 
able intervals of from a few hours to a month. The only 
result of the operation, which was performed on the left 
side, was contraction of the left pupil, redness and increase of 
temperature on the left side of the face, increase of secretion 
from the nose on that side, and headache. These symptoms 
lasted 8 or 9 days. In cases of genuine epilepsy, with no 
history of injury, a fixed point of tenderness can often be 
demonstrated. Kuemmel thinks an opening into the skull 
at this point is often of service, as, in his opinion, the 
tenderness indicates some intangible lesion of the bone or 
meninges. He has never found a demonstrable change in 
the bone removed, but has, in all but one case, found that 
the operation was followed by a cessation of the paroxysms, 
of variable duration, and a decided improvement of the 
mental faculties. Case IV is the same person as case III, 
from whom the superior cervical ganglion had been re- 
moved some time before. A button of bone was removed at 
a tender spot on the left parietal bone. The dura and cortex 
were normal. The defect in the bone was closed by a 
decalcified bone plate. Before this operation, the fits had 
become more and more frequent, and the stupidity more 
marked. After this operation, no fits occurred for 2 weeks, 
then several mild ones in 5 days, and then none for over a 
year, when a single severe fit occurred. The result in this 
case was great improvement. Case V, girl 26 years old, 
duration of disease 12 years. Improvement lasted for some 
time, when she was lost sight of. Case VI, female aged 21, 
showed no improvement whatever. Case VII was a boy of 
5, who had fits for 3 years, beginning like petit mal but 
becoming more severe and frequent. A constant point of 
pain was found on the right parietal bone near the coronal 
suture. Trephining was followed by cessation of the attacks 
for 2 weeks when they recurred in a much milder form. 
The improvement in the mental faculties was striking. 
This patient will be mentioned again. In Jacksonian 
epilepsy, which is most frequently induced by traumatism, 
surgery achieves its most signal successes in this field. K. 
reports 3 cases. Case VIII, aet. 34, received a blow on the 
head from a blunt rapier, which did not break the skin, 7 
years before. No immediate result followed, but several 
days later he became unconscious and remained so for 12 



1892.] SURGERY AND TRAUMATIC NEUROSES. 83 

days. The first epileptic attack occurred 4 years later. 
This, like all the later ones, began in the right arm and 
eye. The attacks became more frequent as time went on. 
On examination a very fine, but sensitive scar, was found 
over the left parietal bone. On laying bare the dura the 
bone was found normal; the dura, however, was thickened. 
This was excised with a thin layer of the cortex. No epilep- 
tic fits had occurred up to 3J years after. Case IX is the 
boy (case VII). The spasms, which had recurred, presented 
an entirely different aspect. They now plainly began in 
the right side of the face and the right arm. The left motor 
area being exposed was found to be normal. On this 
account the operator could not bring himself to excise the 
cortex, which omission he regretted later. He contented 
himself with removing several ridges on the inner sur- 
face of the excised piece of bone and replacing the latter. 
The fits recurred in 3 weeks. Kuemmel announces his 
intention of again exposing these centres and excising them. 
Case X was a man, aged 20, who received a wound 
above and in front of the left ear. This healed promptly 
but various cerebral S}^mptoms soon set in, so that less than 
2 months after the injury he was admitted to the hospital 
with the following symptoms: imperfect speech, paresis of 
right side of face, inability to close the right eye, choked 
disc, almost complete amblyopia, right-sided deafness and 
paresis of the right arm, as well as epileptic convulsions of 
a cortical type. Trephining over the site of the scar showed 
a tear and adhesion of the dura. The dura was excised, 
the brain protruding. The decalcified bone plate inserted 
into the cranial defect was pushed out by the bulging brain. 
All symptoms vanished after the operation, a hernia cerebri 
remaining. In conclusion, Kuemmel reports a case of 
temporary resection of the skull in the case of a congenital 
epileptic idiot 3J years old. A depression of the skull was 
found near and below the lambdoid suture. The blade of 
the obstetric forceps used at birth was blamed for this. A 
piece of bone as large as the palm of the hand, including 
the depressed piece, was resected. It was found that the 
depression showed on the inner surface as a ridge which 
left a very distinct impression on the surface of the brain. 
This ridge was chiselled off and the bone replaced. Within 
2 months the child had learned to sit, to walk alone and to 
feed itself, all of which was impossible before. The epilepsy 
had vanished after the operation. The mother has lately 



84 neurological. [Sept., 

reported constant satisfactory progress. — (Dr. H. Kuemrnel, 
Deutsche Med. Wochensch., No. 23, 1892.) 

G. K. KAUMHEIMER. 

Operative Treatment of Epilepsy. — Kummel refers to 
two cases in which the vertebral arteries were ligatured for 
genuine epilepsy with very temporary benefit, and to 
another case in which the superior cervical ganglion was 
extirpated. Four cases are recorded in which trephining 
was practiced over definite tender spots, with a longer or 
shorter cessation of the fits and with considerable mental 
improvement. A further case died in consequence of oper- 
ation. Author says that the results in such cases of idio- 
pathic epilepsy cannot be looked upon as very satisfactory, 
and doubts whether any case has been really cured. The 
so-called reflex epilepsy is next referred to. Cortical, or 
Jacksonian epilepsy, almost always traumatic in origin, is 
the most important in regard to surgical treatment. After 
giving some details in regard to method of operation and 
localization of lesion author relates three cases: (1) A 
man, aged 34, received blow on head in 1881 ; four years 
later fits began. They started in facial area and arm, be- 
came more frequent later, and intense headache supervened 
in 1887. Trephining was practiced in 1888 at site of a ten- 
der scar over parietal bone. Nothing on inner surface of 
bone but dura mater was adherent to parts beneath and 
presented a cicatricial appearance. It was excised. Patient 
has remained quite well since operation, three and one-half 
years ago. (2) Boy, aged five ; previously trephined but with 
only passing benefit. Fits affected left arm and face. The 
corresponding centres were exposed but no pathological 
change was found. Fits returned later. Author thinks 
that he will have to remove these centres. (3) Lad, aged 
twenty; had a blow on head in Sept., '91. Ten days later 
there was spasm in right arm and face. Speech, sight and 
hearing became affected. Slight paralysis of face and right 
arm. Choked disc present. Patient was trephined over' one 
of two cicatrices. A rent in the dura mater and adhe- 
sions were found. This part of dura mater was excised. 
Patient recovered perfectly from the symptoms, a prolapse of 
the brain alone remaining. Author then refers to the 
case of an idiot, aged three years, who had frequent fits. A de- 
pression was found near the lambdoid suture, probably the 
result of injury during birth. A large piece of bone was 
temporarily resected and a deep depression was found in the 



1892.] SURGERY AND TRAUMATIC NEUROSES. 85 

brain. The corresponding bony projection was removed. 
Very great improvement followed while the child continued 
under observation. Later its mental development was still 
progressing and there had been no fits. — (Brit. Med. Jour., 
July 9, 1892.) 

B. X. CAPLES. 



The Surgical Treatment of Epilepsy. — Dr. Sachs gives 
a record of his joint experience with Dr. Grester in the sur- 
gical treatment of epilepsy, before the Amer. Neurological 
Ass'n. The cases reported upon were either of distinct 
traumatic origin or those in which a strictly localized con- 
vulsion pointed to a limited focus of disease. Author was 
of the opinion that it was not necessary to map out upon skull 
brain areas to be operated upon. Thought the application 
of faradic current to dura would help to localize the centres 
much more accurately than any of the customary rules. 
Where brain had been seriously altered by disease it might 
not respond promptly to current. In several cases there 
had been a diminution of attacks immediately after opera- 
tion, and in some, improvement lasted for three months. In 
other cases attacks recurred after a lapse of several months, 
or less time. Could not report a single decided cure. The 
only hope from surgery was in prompt interference in 
injury of skull to remove the focus of disease before 
secondary changes had been set up. It was the opinion of 
these observers that the way to cure epilepsy was to prevent 
its development by early operation. — ( New York Med. Jour., 
July 30, 1892.) 



B. M. CAPLES. 



Myxcedema after Thyroidectomy. — Natier (Rev. Internet, 
de Rhin., de Otol., et de Laryng., May, 1892) reports a case of 
myxcedema, with complete paralysis of the right vocal cord 
and paresis of the left, occurring after thyroidectomy in a 
27-year-old man. 

J. G. KIERNAN. 

Traumatic Neuroses in Children. — Dr. Vibert (Prog. 
Med., June 18, 1892) cites the case of a two and one-half-year- 
old girl who was found in a car after a railroad collision. 
She had received a slight frontal contusion, had not been 
rendered unconscious, but was in such an agitated state that 
soon after she tried to throw herself out of her father's arms 
while seated on the top of an omnibus. Vomiting came on 
and was followed by a week of acute hallucinatory insanity 



86 neurological. [Sept., 

with terrifying sights of flames, wild beasts, etc. In a week 
these acute symptoms disappeared but a complete change of 
character was noticed. Hitherto sweet-tempered she became 
difficult to manage, sad and taciturn. From time to time, 
without observable cause, her face paled, she assumed an 
expression of extreme terror, had hallucinations of 
the type past described and then returned to the normal 
state. Hitherto careful in her habits she began to wet the 
bed. There was no evidence of nervous attacks nor lack of 
sensibility. There was no heredity. Slight amelioration in 
bed-wetting followed treatment. The second case was that of a 
five-year-old boy upon whose forehead a plank bad fallen, 
which had resulted in half an hour's loss of consciousness. 
Later the patient had meningitoid symptoms and vomiting. 
There were no convulsive attacks but later the character 
changed much. He became sad, suspicious and slept badly, 
his sleep being broken by terrifying dreams. Dr. Gilles de la 
Tourette was astonished to find Dr. Vibert using a term 
(traumatic neurosis) which had been abandoned by scientists. 
The two cases suggested hysteria, which in children often 
took just such forms. Dr. Christian called particular atten- 
tion to the symptom, vomiting, which, joined to the other 
symptoms described, indicated in both a true cerebral com- 
motion. The prognosis in his opinion was grave. Dr. Vibert 
did not think that there occurred in either case cerebral com- 
motion or meningitis. He asked if " traumatic neurosis " 
were not as precise as "traumatic hystero-neurasthenia." Dr. 
Gilles de la Tourette said that the two terms were not 
synonymous. Oppenheim, who had created the term 
" traumatic neurosis," admitted that it lacked scientific pre- 
cision. Dr. Gamier was of opinion, like Dr. Vibert, that both 
cases had a cerebral character. They should be entitled 
" cerebral accidents of traumatic origin in children." 

J. G. KIERNAN. 

Recent Literature on Traumatic Neuroses. — Owing to 
the insurance laws of the German empire, traumatic neur- 
osis continues to occupy the attention of our German 
colleagues and to furnish the basis for considerable literary 
activity and some acrimonious personal discussions. Dr. C. 
Hubscher (Deutsch. Med. Woch., No. 17, 1892) has found in 
six cases of neurosis following injury, motor asthenopia on 
convergence. On approaching an object to the eye, binocular 
vision became impossible at a point from 2 to 4 times the 



1892.] SURGERY AND TRAUMATIC NEUROSES. 87 

distance obtained with a normal eye. At the same time, the 
motor range of vision was normal. Wilbrand, in collabora- 
tion with Saenger, of Hamburg, (Deutsch. Med. Wochensch., 
No. 17, 1892) has investigated the behavior of the visual 
field in traumatic and functional neuroses. He divides 
these cases into three groups. Group 1 includes those who 
make no complaint of ocular or visual troubles ; group 2 
includes those cases with asthenopic troubles, but without 
demonstrable lesion of the central nervous system, or its 
bony envelopes. This group includes most of the cases 
observed. The asthenopic symptoms may be classified as : 

(a) contraction of the visual field, more or less pronounced ; 

(b) symptoms of extraordinary exhaustion of central or 
eccentric vision, or both, producing central exhaustion- 
scotoma or an increase in the contraction of the visual field ; 

(c) photophobia; (d) photopsia in the form of bright or 
colored bodies ; (e) hallucinations of sight ; (/) diminution 
in the acuity of central vision ; (g) paroxysmal increase or 
decrease in the apparent size of objects; (h) monocular 
polyopia ; (i) weakness of accommodation ; (Jc) paroxysmal 
diplopia; (I) sensations of vibration ; (m) tonic or clonic 
blepharo spasm. The pupils are usually normal, but may be 
unequal ; the fundus is always normal. Group 3 includes 
the cases in which, in addition to some of the symptoms of 
the preceding group, a demonstrable lesion of the cerebro- 
spinal system, its bony envelopes or peripheral nerves is 
present. Here the symptoms of the organic lesion are 
added to the functional disturbances. In a fourth group 
might be included the traumatic neuroses of nervous chil- 
dren, which have long been known to the ophthalmologists. 
Wilbrand and Saenger have examined 60 individuals, some 
simply "nervous," some the subjects of functional neuroses, 
and found that the symptom-complex of nervous asthenopia 
was the same in all neuroses, and in nervous school children, 
as well as in adults suffering from neurasthenia, hysteria and 
chorea, with the exception that in hysteria the spastic or 
paretic element may predominate. They found, associated 
with all these forms of nervous asthenopia, disturbances of 
cutaneous sensibility in the form of zones and spots of 
hyperesthesia, hypsesthesia, analgesia or paralgesia, extend- 
ing in some cases to anaesthesia of a limb or of half the 
body. Further, increase of cutaneous and tendon reflexes, 
occasionally unequal on the two sides, and an increased 
vaso-motor irritability were found. The psychical shock will 



88 neurological. [Sept., 

produce a traumatic hypochondria, neurasthenia or hysteria, 
according to the predisposition of the affected individual, 
and the authors prefer these expressions to that of trau- 
matic neurosis. In fact, a number of German authors are 
inclined against the use of the latter term as being too in- 
definite and including too many varying and contradictory 
symptom s. Inasmuch as no case presents all of the symptoms 
recounted, it is not surprising that not all the cases of trau- 
matic neuroses present a contraction of the visual field. 
If the patient makes no complaint of his eyes, their exam- 
ination is often neglected, or only one eye may be exam- 
ined as a matter of form. Besides this, differences of 
method give variance in the results. The size of the visual 
field, as is well known, varies with the size of the test-object 
and the distance at which it is held, as well as with the 
direction from which it enters and leaves the visual field. 
Very slight contractions have the same symptomatic value 
as those of greater degree. Like all other functional ner- 
vous symptoms this is extremely variable in intensity and 
duration. The cases of optic atrophy reported by Oppen- 
heim are probably cases of injury to the nerve in the optic 
canal, due to fracture at the base. In rare cases, a pale pap- 
illa, in an anaemic individual, may be mistaken for an 
atrophic one. In conclusion, Wilbrand states that, in his 
opinion, it is absolutely impossible for anyone to consist- 
ently and successfully simulate even a slight contraction of 
the visual field. In cases of doubt the presence or absence 
of disturbances of sensation and the increase of the tendon 
reflexes, would settle the question. This article has been 
published in book form. (See Literature.) Per contra, 
Schmidt-Rimpler (Deutsch. Med. Wochensch., No. 24, 1892) 
states, from his experience as an examiner of recruits, that 
contractions of the visual field are often simulated to such 
a degree as to require all the patience and knowledge of the 
expert to expose the fraud. It is mainly done by the sub- 
ject denying vision entirely until the object is brought into 
the field of distinct vision. While the object is in the zone 
of indistinct vision they claim they cannot see it. By this 
means, the same result is obtained upon repeated examina- 
tion. By varying the size of the test object and by campi- 
metric tests, aided by the stereoscope and prismatic lenses, 
he has been able to detect a large number of malingerers, 
many of whom confessed the fraud and were able to do full 
military duty. Nonne (Deutsch. Med. Wochensch., Nos. 27-29, 



1892.] SURGERY AND TRAUMATIC NEUROSES. 89 

1892) relates a number of selected typical cases of nervous 
troubles, both functional and organic, following injury, and 
reaches the following conclusions: "The typical clinical 
picture of commotio spinalis, of hysteria and neurasthenia, 
as well as the clinical symptoms of organic spinal and cere- 
bral lesions, may result from traumatisms of different 
varieties". Although he does not doubt but that all the 
cases related can be consistently classified as belonging to 
the "traumatic neuroses" of Oppenheim, he is in favor of 
retaining the specific names of the symptom-groups pre- 
sented. The adjective "traumatic" might be appended. 
In this he agrees with Jolly, Eisenlohr, Schultze and Wil- 
brand. In regard to the disturbances of sensation he has, 
in some of the most severe cases of nervous trouble follow- 
ing traumatism, found them either absent, or trivial and 
evanescent. In others they were present to a varying de- 
gree. Contraction of the visual field was absent, in five 
cases (out of fourteen) ; in three it accompanied traumatic 
hysteria ; in two, organic brain lesion ; in one, severe cere- 
brospinal neurasthenia. In one case no reliable result was 
obtained. The psychical troubles, upon which Oppenheim 
lays such stress, were present in one case only. The cases 
with organic symptoms seem to become stationary 
or progressively worse, while the hysterical cases 
usually tend to recovery. The location of the injury 
seems to have some influence upon the location of the neurotic 
symptoms. Simulation was never found ; exaggeration of 
symptoms was proven in two cases. Neuropathic heredity 
was present in only one case; of other predisposing causes 
chronic plumbism was found in one case. Careful investi- 
gation proved the existence of nervous symptoms before the 
injury in one case, which recovered in a relatively short 
time. The symptoms could be attributed to alcoholism in 
one case. A second edition of Oppenheim's work, " Die 
Traumatischen Neurosen, etc." has been issued. 

G. J. KAUMHEIMER. 

PSYCHOLOGICAL 



PATHOLOGY AND SYMPTOMATOLOGY. 



Outlines of a Psychiatric Symptomatology. — The 
nomenclature of the symptoms of mental disease presents 
peculiar difficulties. The great variety of mental disturb- 



90 psychological. [Sept., 

ances, together with the vast differences even in normal 
mental types, makes it still more difficult for any man, 
however experienced, to cover the entire field of possible 
cases with his personal experience. It is in the study of 
other men's cases that the need of some systematic classifi- 
cation of mental symptoms is most acutely felt. Wernicke 
states that the same symptom may be produced in different 
ways. For example, mutism may be psycho-motor in 
origin ; it may be purely psychical, as a result of delusions 
or mental hebetude ; or it may be psycho-sensory, being 
caused by abnormal sensations in the tongue, throat or 
other parts. The nomenclature should correspond, at least 
in meaning, with the following classification: psycho- 
sensory anaesthesia, paresthesia or hyperesthesia ; intra- 
psychical afunction, parafunction or hyperfunction ; 
psychomotor akinesia, parakinesia or hyperkinesia. The 
necessity of a classification of the contents of our conscious- 
ness, so far as it is identical with the sum total of memories, 
requires another division which Wernicke has found prac- 
tically useful. He divides consciousness into that of 
corporeality, of the surroundings, and of the personality. 
The disturbance of secondary identification is frequently 
confined to one of these divisions, and might be expressed 
as somato-psychosis, allo-psychosis, and auto-psychosis re- 
spectively. This is only intended as a preliminary sketch 
of what is necessary to bring the student to a clear under- 
standing of the concrete case, "and will save him the trouble 
of learning the useless, nay, even detrimental art of crowd- 
ing a clearly comprehended picture of a case into the 
Procrustean bed of an artificial classification." — [Berlin. Klin. 
Wochenschr., No. 23, 1892.) 

G. J. KAUMHEIMER. 

Dental Anomalies in the Insane. — Luzenberger (Italian 
Freniatrical Soc, 1891, Abstr. in Archivio Italiano) reported 
the results of the examination of one hundred men and 
seventy-two women in the provincial asylum of Naples, as 
to the dental peculiarities they presented. The frequency 
of these was found to be ten times as great as in normal 
individuals. The special deviations from the normal that 
were most frequent or notable were : A sort of trapezoid 
shape of the lower jaw, the incisors in a straight line, the 
canines slightly salient at the angles; a tendency of the 
teeth to converge inward toward the palate, to which the 
author gives the name of opristhogenism alveolare. The 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 91 

greater number of deviations were met with in the posi- 
tions of the teeth. As between the two sexes the women 
seemed to have, in the cases observed, the better dentition. 
Heterotopia was not infrequent. Supernumerary teeth were 
observed only once in full development, and two enormous 
supernumerary teeth in one other individual. The specialties 
in form of teeth most prominent, were a small cylindrical 
shape of the canines, and the molars a crescenza, or with 
pithecoid tubercles. The statistical tables are divided 
according to diagnosis and morbid heredity. Certain forms 
of marked atavism, such as the tubercle of Carabelli and the 
molars a crescenza (second much longer than first) are found, 
as a rule, in psychopathies of a degenerative character. 
Others, especially the small and equal incisors that recall 
the dentition in some of the lower mammalia, are met with 
more frequently in the psycho-neurotic forms of insanity, 
suggesting a doubt whether they could be considered 
atavistic peculiarities, or those, perhaps, of the psycho-neu- 
roses, but developed in an originally defective organism. 

H. M. BANNISTER 

Cranial Anomalies in the Insane. — S. Beauchi and 
Fr. Marmo (Revista Sperimentale, XVIII., April, 1892) 
publish the results of an examination of over a thousand 
(1,019) crania of the insane from the Manicomio of Reggia- 
Emilia, which are illustrated by ten elaborate tables in ad- 
dition to the text. The form of insanity was known in 
each case and the anomalies are tabulated in accordance. 
The authors divide the whole into the two general divisions 
of congenital and acquired insanities, including in the 
former all the cases of idiocy, imbecility, epilepsy, hysteria, 
paranoia and periodic psychosis, and the latter comprising 
all the other forms. The general results are stated as fol- 
lows, the percentages on the whole number of each class 
being given : 

TYPE OF INSANITY. 
Anomalies found — Congenital. Acquired. 

Metopic Suture 13.72 8.54 

Frontal Process of Temporal , 

Median Occipital Fossa 

Frontal Crest 

Pterygo-Spinous Foramen 

Third Condyle 

Lemurine Apophysis 

In their discussion of their figures the authors disclaim 
any intent of generalizing from these comparatively few facts, 
and agree that some consideration must be taken of the popu- 
lation to which the crania examined belonged, and that a 



1.30 


.92 


5.22 


4.50 


15.03 


20.78 


4.57 


2.42 


.65 


.46 


1.33 


3.46 



92 Psychological. [Sept., 

comparison is yet needed of crania of normal individuals 
from the same region. It is noteworthy, however, that the 
anomalies are more frequent in proportion in the congenital 
or degenerative forms than in the simple psychoses. The 
comparatively small number of the former (63 males, 90 
females) out of the total series examined, leaves much to be 
desired, but the average is certainly higher. The apparent 
exceptions to this, the greater percentage of frontal crest and 
of the lemurine apophysis amongst the acquired forms, lose 
some of their force as such, from the fact that the most de- 
veloped types of the former were observed in the congenital 
forms, and the latter seems to be almost a sexual peculiar- 
ity, only four out of thirty cases being in female crania. 
The authors do not consider these anatomical abnormali- 
ties as causes, but rather as concomitants of the insanity. 
An unstable nervous system would be likely to have 
other coexisting vices of conformation. It might be sup- 
posed that the persistent metopic (median frontal) suture was 
due to greater development of the frontal lobes, but it is 
found most frequently in idiots and imbeciles. It cannot be 
admitted that a cerebral alteration could be able to so 
develop the squama of the temporal as to produce a true 
temporo-frontal process. Medical literature has numerous 
cases that contradict the probability of 4he medio-occipital 
fossa being due to over development of the vermis, and it 
suffices to consider the position and relation and slight ex- 
tent of the frontal crest to show that it can hardly be ad- 
mitted as dependent on any lack of development of the 
frontal lobes. As regards the pterygo-spinous foramen, the 
third condyle and the lemurine apophysis, they are all too 
remote from the cerebrum to hold that its altered function 
could give rise to their abnormal organization. 

H. M. BANNISTER. 

Pelvic Region Anomalies in the Degenerate — Dr. E. 
Laurent states (Arch, de Anthrop. Crim., Jan., 1892) that in 
degenerate criminals there are frequently encountered anom- 
alies of the size of the penis; incomplete development or 
atrophy of this organ similar to that found by Bourneville 
and Sollier in epileptics and paranoiacs. Hypospadias is 
much more frequent than epispadias. The male pelves are 
frequently infantile or feminine in type. Congenital devia- 
tions of the pelvis are comparatively frequent. 

J. G. K1ERNAN. 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 93 

Temperature in the Insane. — Gonzales and Verga in a 
paper read before the Italian Freniatrical Society (Archivio 
Italiano, XXIV, V and VI, 1891) reported the results of 
investigations, suggested by the thermometrical asymmetry 
reported by Tonini in epileptics, which they had undertaken 
to test the possible differences of temperature of the two 
sides of the body in the insane. Their subjects were ten 
cases of epileptic insanity, five of hysteria, six of moral 
insanity, two of impulsive monomania, three of alcoholism 
and five of pellagrous insanity. For purpose of comparison 
they tested ten robust and intelligent attendants. Their 
conclusions were as follows : "(1) Exceptionally in normal 
individuals, frequently in the insane, there is found in the 
same subject different temperatures on the two sides 
of the body. (2.) In normal subjects the temperature 
is either alike in the two axillse, or, if it is higher in 
the right, the difference is not more than one-tenth of a 
degree. (3.) Hysterical and epileptic insanities give the 
greatest number of cases in which the temperature of the 
left side is the greatest as compared with other forms, both 
as regards number and intensity ; fifty per cent, in the 
first, and forty per cent, in the second. The re- 
verse is also very numerous and this in the same 
proportion. (4.) According to their examinations, moral 
insanity gives about thirty-three per cent, of highest 
temperature on the left, and alternating. The constant 
temperature of the two sides in the same subjects is not so 
frequent, but we meet more often than in the preceding 
forms the same temperature in repeated examinations. 
(5.) In alcoholic and pellagrous insanity, the temperature 
varies in the right and left in the same individual, without 
any special numerical predominance of one side over 
the other, and the temperatures are equal more fre- 
quently than in moral insanity ; about half. In 
pellagrous insanity is observed a greater intensity of tem- 
perature on the left side. ( 6. ) Age has no marked 
influence upon the temperature difference of the two sides of 
the body". The authors intend to carry on their observa- 
tions on a more extended scale. 

H. M. BANNISTER. 

Verbal Blindness. — Bianchi (Italian Psych. Soc, 1891, 
Abstr. in Archivio Italiano) reports four cases illustrating 
types of verbal blindness, from the analysis of which he 
deduces the following conclusions : " 1. Verbal blindness is 



94 psychological. [Sept., 

not of itself a special form of disorder of speech, but is a 
very variable symptom-complex that might be better desig- 
nated by the name of optic aphasia, as proposed by Freund. 
2. The memory of places, as well as that of written words, 
of objects, of written musical notes, is a visual memory and 
is localized in the visual area, varied according to individ- 
ual conditions. In general, we can not speak of memory, 
but of memories, which are, as it were, homologous groups 
of sensations and of movements respectively located in the 
cerebral cortex. 3. We do not accept, in the sense used by 
Munk and his followers, the distinction between psychic 
and cortical blindness. The blindness for written words, as 
well as that for objects and that for light itself, are ail psychic 
blindnesses, and the term cortical blindnesses is merely 
a pleonasm, since all psychic blindnesses are either cortical 
or associative. 4. Amnesic aphasia, as a particular clinical 
form specially localized, does not exist. Amnesic aphasia 
is a symptom connected with the function of the sensorial 
centres for language ; it may originate, therefore, from the 
destruction or the paresis of the auditory images of words 
in the auditory form, and the destruction or paresis of the 
visual images of words in the visual form, as in the fourth 
patient whose case was reported, in whom through his 
whole life the typographic memory was eminently a visual 
one ; it may arise, however, from a functional deficiency of 
the whole sensory area, giving rise to difficulty in the re- 
calling, either spontaneous or volitional, of representative 
images." 

H. M. BANNISTER. 

Verbal Psycho-Motor Hallucinations, according to 
Seglas (Arch, de Neur. May, 1892) seem to be frequent in 
melancholiacs. They may be taken for verbal auditory 
hallucinations, and perhaps these last should be considered 
rare if, before admitting them, the possibility of internal 
voices, illusions and delusional interpretations be eliminated. 
In a general way it may be said that the mental state of 
melancholia is not suited to the development of verbal 
auditory hallucinations. If these occur, there is strong 
reason for suspecting the coexistence of another psychosis. 
Seglas once more reiterates the proposition so frequently 
needed by British Philistines, that stupor due to the presence 
of hallucinations should be distinguished from stupor proper. 

J. G. KIBBNAN. 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 95 

On Fixed, or Dominant Ideas. — A number of cases of 
mental alienation occur in which the only departure from a 
normal standard is the prevalence of a fixed, or dominant 
idea. These are the cases which were formerly classified as 
monomanias. A familiar form is querulous insanity (Quer- 
ulantenwahn), but the ideas may involve almost any sub- 
ject. In the type mentioned, it involves a real or fancied 
injustice. According to Wernicke's classification (see present 
number of Journal) they would be circumscribed autopsy- 
choses. Every dominant idea shows the peculiarity that it 
becomes the infallible criterion of all further experiences 
and is incapable of correction by contrary experiences. In 
this they approach the hallucinations. They are usually 
very chronic or incurable, although the patient may learn 
to suppress his dominant ideas. Wernicke cites a case 
where a patient, on realizing that he would have to abandon 
his constant clamor for justice in order to be released, did 
so, and has lived quietly at large for over four years. — (Prof. 
Wernicke, Deutsche Med. Wochenschr., No. 25, 1892.) 

G. J. KAUMHEIMER. 

Negative Delusions — Dr. Camuset (Progres Med., Aug. 
6, 1892) concludes that whatever be the type of their psy- 
chosis, melancholiac delusions are likely to be of negative 
type; not so with the persecutory delusional lunatics. Delu- 
sional negative conceptions are often manifested during the 
course of anxious melancholia. Certain anxious melan- 
choliacs resemble the negative delusional type described by 
Cotord, but are not so nosologically distinct as to merit 
special classification. Prognosis depends upon the psychosis 
presented. Intermittent vesanias of this type do not recover. 
Most of the negative delusions occur in females and most fre- 
quently in families of degenerative taint. In depressed 
senile psychoses negative delusions occur. Patients destined 
to become negative delusional lunatics are sombre, taciturn, 
timid and often present degeneratial stigmata. Negative 
delusions are often found among paretic dements. Regis 
was of the opinion that negative delusional insanity, as 
described by Cotord, merited a nosological place among the 
psychoses. He cited what he considered a typical case, 
which presented anxious melancholia, ideas of possession 
and of damnation (the patient believed he was a devil or 
part of one), propensity, suicid.e and auto-mutilation, hypo- 
chondriacal notions as to the non-existence of his body, soul, 



96 psychological. [Sept., 

or of God. The patient believed that he had neither heart, 
lungs, tongue, eyes, nor any other organ, but had turned into 
stone. He also claimed that being turned into stone he was 
immortal. Dr. Seglas thought that beside the negational 
delusions found in paretic dements, imbeciles, and the senes- 
cent, there existed a negational delusional insanity. 

J. G. KIERNAN. 

Auditory Hallucinations in Facial Neuralgia. — Dr. 
Fere reports (Mercredi Med., May, 1892; a case of an epileptic 
with trifacial neuralgia complicated by zona, in which 
menacing voices were heard on the affected side. The 
patient was conscious of the abnormal nature of the voices. 
There was at the same time an intense sialorrhcea which 
made its onset with the neuralgic symptoms and the voices, 
and which disappeared with them. The epilepsy, Fere 
points out, predisposed to the hallucinations. 

J. G. KIERNAN. 



The Unilateral Hallucination, according to Dr. 
Toulouse ( Gaz. des Hop., June 4, 1892) is a symptom of con- 
siderable clinical value. It may be of two origins ; a local 
sensorial, or a cerebral. The diagnosis will turn on the 
examination of the sense organ affected. In case no lesion 
be found there, but other sensory and motor disorders exist, 
the hallucination is due to a cerebral cause. 

J. G. KIERNAN. 

Folie a Deux with Remarks upon Similar Types of In- 
sanity. — Dr. C. K. Mills presented notes on two cases of 
this disease before the Amer. Neurological Ass'n. Patients 
were sisters, the eldest thirty-two years of age, the other two 
years younger. The father was a hard-drinking, quarrel- 
some man. The first patient had been deranged for three 
or four years. Complained of strange feelings, as of some- 
thing growing in her abdomen, of sickness of the 
the stomach, bloody passages, chills and other unpleasant 
sensations. Had been troubled for a long time with strange 
voices. Was tormented by people both at her work and at 
home, and was made to say very ridiculous things. 
Apparently had hallucinations of several senses. A stench 
of blood came up through her throat; at times she was 
grasped by a hand. Men would appear before her and 
sometimes they would get on their knees and solicit her, 
and she was full of sexual delusions. The heads of men 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 97 

would appear before her at her work. When she did not 
see them she would feel them or hear them. Often heard 
their voices talking with her after midnight saying all 
sorts of filthy things. The other patient's mental disturb- 
ance had come on a few weeks after that of her sister. 
Symptoms were much the same as those in the former case. 
Both appeared to believe firmly in what they said, and yet 
at times to appreciate that something was wrong in their 
heads. They presented, as is not unusual, a blending of the 
characteristics of the three forms of folie a deux, that is, of 
the imposed insanity, the simultaneous insanity and the 
communicated insanity. The influence of heredity was 
decided. The delusions were persecutory. — (Med. Record, 
July 30, 1892.) 

B. M. CAPLEP. 



Morbid Sexual Excitation. — Ball, in a recent lecture 
(Jour, de Med. de Paris, June 26), divides the psychical dis- 
orders of sexual passion into: I. Erotomania (the chaste 
type); II. Sexual excitation (five forms, the hallucinatory, 
the aphrodisiac, the obscene, nymphomania and satyriasis). 
III. Sexual perversion, (four types, the sanguinary, necro- 
philiac, paederasts and interchanged.) In the hallucinatory 
type the persecutory lunatic experiences sexual persecution. 
Mania, puerperal insanity and "religious" insanity furnish 
frequent examples as also do alcoholic lunatics. One hypo- 
chondriacal paranoiac was, he claimed, turned into a female 
prostitute and could not eat his meals because his nose, 
mouth and intestines were gorged with sperm. The aphro- 
disiac type has the sexual appetite enormously exaggerated. 
Nymphomania, in Ball's opinion, is a grave symptom of an 
often fatal psychosis. It may be a chronic or slight type, 
and an acute or grave type. The grave type resembles 
typhomania with a sexual symptom. 



J. G. KIEHNAN. 



Passivism (a type of sexual perversion seeking delight in 
self pain, which Krafft-Ebing has designated Masochism), ac- 
cording to D. Stephanowski, consists (Arch. d. FAnthrop. Grim., 
May, 1892) in the absolute subjection of the will of one person 
to the profit of another for an erotic end, with an intense desire 
for abuse and maltreatment. The phenomena of passivism, 
(which is the antithesis of sadism) is divisible into moral 
and physical types. The first consists in debasement and 



98 psychological. [Sept., 

humiliation before a woman, or (if a perversion exist) before 
another man (fellateurs), cunnilungus, stercovaires, etc. 
Physical passivism consists in flagellations, blows, etc. 
Stephanowski cites instances to prove that flagellation often 
acts psychically and not always physically. Normal love 
makes sacrifices, but that is not passivism. The pathological 
factor enters when such sacrifices are made without seem- 
ingly adequate cause when the lover submits to fustigations 
for the sole purpose of exciting his sensuality. Passivism, 
according to Stephanowski, is a survival of the courtship 
paid by male animals to female animals to gain their favors; 
it is a pathological exaggeration of this courtship. 

J. G. KIBBNAN. 

Reflex Iridoplegia in General Paralysis. — Redlich 
has investigated the iridal contractility to light in general 
paralysis of the insane with special reference to consensual 
reaction. In all cases examined by him he found that if 
each iris reacted to direct light stimulation the consensual 
activity was intact in each eye, but if neither iris responded 
to the incidence of light upon its retina there was complete 
absence of consensual motility in both irises. In all cases 
presenting loss of direct light reflex in one eye only, 
illumination of that eye caused consensual action in oppo- 
site iris ; on the other hand, no pupillary change in irido- 
plegic eye resulted from exposure to light of sound eye. 
He concludes that these phenomena can only be explained 
by a partial decussation of the light reflex fibers of the optic 
nerves, the crossing taking place in such a manner that from 
each optic nerve fibers proceed to the right and left oculo- 
motor nuclei. This decussation must be situated peripher- 
ally to the lesion which causes abolition of the light reflex : 
probably it takes place in the chiasm or posterior com- 
missure. — (Brit. Med. Jour., July 9, 1892.) 

B. M. CAPLES. 



General Paralysis in a Boy. — Charcot and Dutil report 
case of a boy, sixteen years of age, who apparently had gen- 
eral paralysis of the insane. Was one of three survivors of 
a family of eighteen. Father alcoholic and had an attack 
of alcoholic delirium soon after boy was born. When he 
came under observation looked younger than his age, marks 
of puberty being little apparent, as if his physical develop- 
ment had undergone a somewhat sudden arrest. Had the 
characteristic, uncertain, awkward gait; showed fair capacity 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 99 

for attention to questions ; manifestly feeble intellectuality; 
memory notably impaired. Had tremor of tongue and lips 
and difficulty in articulating. Tremor in hands was 
marked; writing was characteristic. Pupils unequal and he 
was subject to attacks of peculiar sensations in different 
parts of his limbs, chiefly on the right side. In one such 
attack there was well marked interference with speech func- 
tions. No exalted ideas were present, but the case presented so 
many other characteristic features as to leave little doubt 
that it should be placed in the category of general paralysis 
occurring at an unusually early age, like several cases 
already recorded in this country and in France. With 
reference to the age of incidence of general paralysis of 
the insane the opinion of Mickle is quoted, viz., that the age 
at which general paralysis develops nowadays is an earlier 
one than it was formerly, and that this is the result of a pre- 
mature senility among individuals and is a precursor indic- 
ative of the decadence of the race. But, perhaps, as is sug- 
gested in the paper under notice, it it is really a result of 
our being now able to diagnose the condition when its signs 
are much less manifest than they had to be before the dis- 
ease could be recognized in former times. — {Lancet, April 23, 
1892.) 

B. M. CAPLES. 



Auto-Injury in Paretic Dements. — Vallen {Prog. Med., 
Aug. 6, 1892) points out that attendants and insane-hospital 
officials are often unjustly accused because of self-injury by 
paretic dements. These patients often keep their limbs 
constantly agitated. Others constantly button and unbutton 
their clothing, causelessly dressing and undressing. Others 
tear their clothes to tatters and use these to bind their limbs, 
thus readily producing bruises simulating linear blows. 
When confined to bed these last injure themselves by tos- 
sing, thereby causing ecchymoses which readily become 
phlegmonous. In some instances scratches of a rather 
serious nature are done by the patient. One such self- 
mutilator laid his testicles bare. 

J. G. KIERNAN. 

Automatism in Paretic Dementia. — Drs. Regnault and 
Azonlar (Progress Med, Aug. 6, 1892) report a case of autom- 
atism in the depressed period of paretic dementia. 

J. G. KIERNAN. 



100 PSYCHOLOGICAL. [Sept., 

Suicide by Bread Crusts in a Paretic Dement. — 
Lizaret {Ann. d Hygien Pub. et de Med. Leg., March, 1892) 
reports the case of a paretic dement who made a saw- 
toothed instrument from bread crusts with which he sawed 
the precordial region. Through the aperture thus made 
he introduced splinters of wood in the direction of the 
heart. 



A Case of Ophthalmic Migraine With Transitory 
Epileptoid Psychosis.— The patient was a young man, aged 
17, who gave a history of a strongly neuropathic ancestry 
and of convulsions in infancy. At the age of 14 several 
attacks of somnambulism occurred. Soon after these the 
patient became sick with influenza, which was followed by 
peculiar mental disturbances. These were marked by a de- 
cided obscuration of consciousness, although allowing a 
certain rapport with his surroundings, by considerable ex- 
citement with occasional tendency to violence, moderate 
mental confusion and great irritability. Occasionally hal- 
lucinations were noticed. These attacks lasted but a few 
hours and usually occurred about bedtime, gradually sub- 
siding into sleep from which the patient awoke the next 
morning with complete amnesia of the occurrences of the 
evening before. These paroxysms were easily produced by 
any extraordinary event which the very excitable patient 
had observed, and which then usually dominated the suc- 
ceeding confusion. Occasionally he felt the attacks coming 
on. Besides this, he very frequently suffered from migraine, 
at times coming on as hemicrania, with vertigo and great 
weakness, at others accompanied by various visual distur- 
bances. The mental disturbance always was preceded by 
the headache, but the latter often continued after the men- 
tal symptoms had again passed off. He recovered under 
bromides, mild hydrotherapy and occasional galvanization 
of the head. The author is inclined to attribute the men- 
tal disturbance to a vasomotor disturbance of the cerebral 
circulation without trying to determine its localization or 
causation. The similarity of the mental symptoms to those 
of a transient epileptic psychosis is obvious. In fact, Ferg, 
in a late monograph, considers ophthalmic migraine as a sen- 
sory epilepsy. Zacher, however, does not agree with him, 
as in this case the migraine ran its course independently of 
the mental disturbance, which only occurred during the 
more severe attacks. Z. has only found one case of mental 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 101 

disturbance following migraine — that of Loewenfeld. Be- 
sides this, Grasset quotes Liveing to the effect that they may 
occur, but does not mention cases. — (Dr. Th. Zacher, Berlin 
Klin. Wochensch., No. 28, 1892.) 

G. J. KAUMHEIMER. 



Alcoholism and Insanity. — The Veroffentlichungen des 
Kaiserl. Gesundheits-Amtes (No. 4, 1892) gives statistics relat- 
ing to this subject, obtained from official sources. Among 
32,068 patients admitted to public or private institutions for 
the insane in Prussia in 1886-88, 3531 (11%) were suffering 
from alcoholic insanity; 154 of these being females. (The 
figures for 1880-82 are 2897 and 150.) Among the 3228 
whose age could be ascertained, 1817 were under 40 years 
old, 1303 were between 40 and 60 and 108 were older. 56.3% 
were under 40 (in 1880 to 1882—54.6%; 1883 to 1885— 
54.7%). Besides, alcoholism was given as a cause in a 
number of other cases. Including the cases of delirium 
tremens, this cause was given in 34.7% in 1886, in 36.2% 
in 1887 and in 40% in 1888, of all male patients in whose 
cases a definite cause could be elicited (5935 cases). These 
figures would be considerably higher if the patients with 
hereditary mental disease, the simply weak-minded and the 
few patients not insane were omitted. In this case the 
figures would be 40.4%, 42.3%, and 44.5% of all male cases 
in which a cause could be elicited. The increasing import- 
ance of alcoholism as an etiological factor is shown by the 
figures of admissions to the general hospitals of the German 
empire (not of the state of Prussia only). In the periods 
1877-79 there were 12,863 ; in 1880-82, 13,346 ; in 1883-85, 
26,359; and in 1886-88, 34,767 admissions for chronic 
alcoholism and mania a potu. At the same time there 
were admitted to the insane hospitals of the empire for the 
same causes: 1877-79, 2,856; 1880-82, 3,574; 1883-85, 
4,545 patients. — (Deutsche Med. Wochenschr., No. 20, 1892.) 

G. J, KAUMHEIMER. 

Mental Disturbance Accompanying Cirrhotic Kidney. 
— Dr. H. Abegg reports a case in which the mental altera- 
tion presented the character of an acute melancholia. The 
symptoms of kidney disease were well marked. Autopsy 
revealed a normal brain, but very markedly contracted kid- 
neys. From an analysis of the accessible literature he con- 
cludes: 1. Psychical alteration, especially of a depressive 



102 psychological. [Sept., 

character, has repeatedly been observed in kidney diseases. 
2. In rare cases, as in the one reported, the mental disturb- 
ance occurring during the course of renal disease can, in all 
probability, be traced to ursemic intoxication. 3. Mental 
disorders, in which this relation can be established, have 
been observed in all the forms of Bright's disease, as well as 
in other diseases of the kidneys. 4. The diagnosis, "men- 
tal disease due to kidney lesion," is only justifiable 
when undoubted symptoms of uraemia, as vomiting, somno- 
lence, dyspnoea or convulsions are present, and when other 
causes, including severe nervous heredity are absent. 

5. There is no specific form of insanity in renal disease, 
although melancholia and stupor are the prevalent forms. 

6. The prognosis is, as a rule, that of the typical ursemic 
attack. 7. In cases which have recovered, a strict milk 
diet has been of favorable influence on the mental disturb- 
ance. — (Berlin. Klin. Wochensch., No. 17, 1892.) 



G. J. KAUMHEIMER. 



Puerperal Mania. — Dr. Elliot thinks the* terms 
"Puerperal insanity," "puerperal mania," and "melancholia 
of lactation" are misnomers; "insanitas in puerpero," "mania 
in puerpero," "melancholia ex lactatio" are the terms that 
should be substituted, since they do not differ clinically 
from insanity, mania and melancholia as usually observed; 
the puerperal state simply precipitates them, either through 
heredity or mental worry before confinement. He gives 
the history of a case in which he was associated with Dr. 
Behrend. Patient was thirty-one years of age, this being 
the sixth confinement. History of hereditary predisposition 
to insanity on her maternal side. June 2 patient suffered 
false pains of labor and became very apprehensive and 
despondent as to termination of her gestation. June 7 
delivery was completed. Patient evinced symptoms of 
religious mania but became quiet under the morphine 
given. Temperature increased for several days and on 
June 11 it was 100.5 degrees. There was slight rambling 
and irrational action. At 1 p. m. patient became maniacal, 
jumping from bed and attempting to reach front window ; 
she was with difficulty restrained. Chloral hydrate and 
potassium bromide, each 15 grs., were given for three hours. 
Condition continued unchanged. June 14 patient presented 
delirium of an hysterical type. June 14 temperature was 
101.82, pulse 120" Elixir of ammonium valerianate and 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 103 

potassium bromide were ordered. Patient remained in 
about this condition until June 21, having been given 
morphine, hyoscine and quinine, besides those remedies 
already mentioned. At this date the woman's condition was 
somewhat improved and she took more nourishment; only 
rambled at intervals. There was no septic condition. At 
8 p. m. suddenly collapsed and could not be revived. Died 
at 9 p. m. of exhaustion. — {Med. News, July 23, 1892.) 

B. M. CAPLES. 

A Bacillus of Eclampsia. — Kaltenbach points out the 
various facts which tend to support the theory of an infec- 
tious origin of puerperal convulsions. A number of authors 
have furnished evidence pointing to this conclusion. Kalt- 
enbach states that the facts in the clinical history of the dis- 
ease which can be best explained by assuming an infectious 
or toxic origin are : 1. The occurrence of the trouble at a time 
when contractions of the uterus are likely to force toxic mate- 
rial into the maternal circulation from the placental site. 2. 
The coincidence of the several convulsions with a labor pain. 
3. Its frequency in twin pregnancies, as opposed to its 
rarity in hydramnios. 4. Its relations to the nephritis of 
pregnancy and the danger of diminished urinary excretion. 
5. The rarity of a second attack. 6. The favorable influ- 
ence of evacuation of the uterus. 7. The frequency of nerv- 
ous and mental sequelae as after other infections. Under 
K's. direction, Gerdes has made exact and exhaustive bac- 
teriological examinations of the organs of a woman dead of 
severe puerperal convulsions. Cultures were made from 
the lungs, kidneys, liver and the aortic blood. In all cases 
a growth developed which consisted entirely of a pure cul- 
ture of a very short, thick bacillus. Its culture showed cer- 
tain characteristic peculiarities. The bacillus proved refrac- 
tory to the majority of staining materials. Staining was 
most successful with a strong alkaline solution of methylene 
blue in the water bath. The ends of the bacilli were stained, 
the centres clear. They were found arranged in chains. 
Injections into mice proved rapidly fatal, clonic convulsions 
occurring in about an hour, followed by death in stupor in 
from nine to twenty hours. Relatively large doses of mor- 
phine, administered previous to the injection of the culture, 
prevented the occurrence of convulsions and saved the life of 
the mammals. This drug, however, only prevents the effects 
of the germ, but does not inhibit its multiplication in the 



104 psychological. [Sept., 

body. The rat is quite refractory to this germ, needing 
large doses. Even then death occurs in stupor without con- 
vulsions. The bacilli were found in large numbers in the 
liver and kidneys of the rat. Rabbits, pigeons and guinea 
pigs are refractory. In the latter, circumscribed necrotic 
patches appeared over the entire body, but death did not 
result. Gerdes does not make any definite claims, but sug- 
gests a very careful bacteriological examination of all fatal 
cases of puerperal eclampsia. He argues that this bacillus, 
so fatal to rats and mice, cannot be indifferent to the human 
body.— (Mm. Med. Blaett., No. 21, 1892.) G . j. kaumheimer. 



In a later article (Ueber den Eklampsiebacillus, etc., Deutsche 
Med. Wochenschr., No. 26, 1892) Gerdes sums up as follows: 
1. The eclampsia bacillus is the sole cause of puerperal 
eclampsia and is found in no other disease, and there can be 
no eclampsia without its presence. The infection proceeds 
from the uterus, probably from an endometritis existing 
prior to conception. 2. The convulsions due to other 
causes, occurring during labor, are to be strictly separated 
on the basis of the post mortem appearances, from true 
puerperal eclampsia. 3. Eclampsia is a well characterized 
disease, strictly limited anatomically. 4. The profound 
changes found in the organs of eclamptic patients post 
mortem are not adequately explained by the demonstration 
of the presence of the specific germ in the body, but are 
probably due, directly or indirectly, to its toxines. 

G. J. KAUMHEIMER. 

Nervous and Mental Complications of Influenza. — Dr. 
Zenner has an article with this title in the Medical Progress 
for August. Some of the most prominent symptoms are 
headache, backache, pain in limbs, a sense of mental and 
physical exhaustion, sleeplessness, vertigo, pain in eyes and 
supra-orbital neuralgia. Other symptoms less common are : 
irritation of brain or meninges, hyperesthesia of special 
senses, convulsions, somnolency or stupor, cerebral and 
spinal meningitis. A limited number of the following have 
been reported : myelitis, polio-myelitis, polio-encephalitis, 
multiple neuritis, hemiplegia, aphasia, paralysis of the 
muscles of eyes and soft palate, inflammation and atrophy 
of optic nerves, epilepsy, chorea, glycosuria, angina pectoris, 
Graves' disease, and various trophic and vaso-motor disturb- 
ances. Disturbances of an hysterical or neurasthenic type 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 105 

are not uncommon. The latter is a nervous complication, 
most frequently seen by the neurologist. A mental type 
with depression of spirits and despondency predominates. 
Prognosis of the mental complications usually favorable; 
duration short. Symptoms often continue for a long time. 
Mental disturbances found may be divided into the febrile 
and post-febrile psychoses. Former assume appearance of 
ordinary febrile delirium, a semi-conscious dream-like state 
with hallucinations and great restlessness and insomnia. 
This is often of short duration, though it may run into post- 
febrile insanity. Most common of latter is melancholia. 
There are all degrees of this disturbance, from the mental 
depression of neurasthenia to deepest melancholia, in which 
acts of desperation, suicide, etc., are attempted. Less fre- 
quently the disease assumes the form of mania, with ex- 
alted mood, rapid speech and actions, or a semi-conscious 
state like that of febrile delirium, or extreme mental con. 
fusion, or an apparent blending of several forms of insan. 
ity. Author thinks the prognosis of the nervous distur- 
bances of influenza is generally favorable. — {Med. Progress 

Aug., 10V&.J B. M. CAPLES. 

Diathetic Insanities. — Mabille (Jour, de Med. de Bor- 
deaux, June 26, 1892) concludes that diathetic conditions may 
produce all types of insanity. 

J. O. KIERNAN. 

Hysterical Anaesthesia, according to Janet (Arch, de 
Neur. May, 1892) is a psychosis, not a neurosis ; a disorder 
of the personality, j. G . kiernan. 

Criminality and Degeneracy. — Morandan de Monteyel 
claims (Arch, del 'Anthrop. Grim., May, 1892) that the crim- 
inal is not a degenerative lunatic but an atavism ; a being 
who has reverted to the savage state. Criminality, in Mor- 
andan's opinion, is in reverse ratio to the degree of degen- 
eracy. Crime, in the strictest sense of the term, is rarer 
among the insane than the sane. Dortal (These de Paris, 
1892) claims, on the other hand, that the born criminal of 
the type just described does not exist. Crime may be an 
epiphenomen in the lives of epileptics, lunatics, beings 
more or less degenerate, or even from such degeneracy. 
Such degeneracy gives the stigmata which may be found 
alike in criminals, paupers, deaf-mutes, epileptics, hysterics 
and lunatics. j. G . kiernan. 



106 psychological. [Sept., 

A Psychological View of Crime. — Dr. A. Van Hoff 
Gosweilder has an article in the Medical Record of Jan. 30 
on the above subject in which he quotes numerous authori- 
ties to sustain his views. He thinks there is need of study- 
ing the organism and its environment, and says the edu- 
cated mind needs little to be convinced that the cause of 
crime and inebriety is often social and psychical, and there- 
fore quite suggestive of a psychical remedy, which, as a 
matter of treatment, is of great import to society. Preven- 
tion, destruction and reformation are the requisites in dealing 
with crime, but the first is the most practicable and valu- 
able. Science and intellectual honesty must be brought to 
the aid of sentiment before alienists, philanthropists and 
governments can possibly reach the best results. 

B. M. CAPITES. 

Dr. J. G. Kiernan, of Chicago, has a very interesting 
article in the April Alienist and Neurologist on "Art in the 
Insane." He not only treats of those peculiar efforts at 
artistic work that are sometimes observed in the insane 
in asylums, but he also treats of the mentality of certain 
well-known artists, such as Turner. We confess that the re- 
marks upon Turner's mental condition are somewhat of a 
revelation to the writer hereof, but if the revelation made 
is correct, this great artist must have been an imbecile with 
only the special talent that is sometimes observed in this 
class. The article is very interesting and instructive and 
treats of a subject that has heretofore been too much neg- 
lected. Dr. Kiernan has the faculty of discovering pearls 
in neglected corners of medical literature and this essay is 
no exception. 

The Insane in Egypt. — Dr. Frederick Peterson has an 
interesting article on this subject in The Med. Record of May, 
1892, which is the result of his personal observation. He 
calls 'attention to the fact that New York city and 
Brooklyn together, with two million inhabitants, have 
asylums that accommodate over seven thousand three hun- 
dred insane ; whereas Egypt, which has six million inhabi- 
tants, has but one asylum, and this contains two hundred 
and fifty patients. While making due allowance for the 
Mohammedan dislike to institutions, and their treating in- 
sane as holy persons, he still concludes that the percentage 
of insane in Egypt is vastly lower than anywhere else in 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 107 

the world. The first asylum in Egypt was founded in 1280> 
A. D., and the patients were treated with kindness. Music, 
dancing and light comedy were features of the treatment. 
In 1800 Napoleon found patients there in chains, and made 
some improvements. Dr. F. M. Sandwith, who visited the 
lunatic asylum in 1883, found the most shocking condition 
of things. The patients were in chains and everything 
else in the institution was in keeping. Dr. Sandwith took 
charge of the institution, introduced a system of kindness, 
furnished competent clerks, and, in fact, completely trans- 
formed the institution architecturally and in its general 
management. At the present time restraint is rarely em- 
ployed. The patients' apartments are neat and clean and 
the attendants are kind and attentive. The doctor found 
that in quite a proportion of the insane the insanity was 
due to cannabis indica. They used the drug by smoking. 
The earlier mental symptom is a marked and increasing 
timidity and often results in chronic insanity, dementia 
or death. General paralysis is very rare and it has yet to be 
proven that it even exists among Egyptians. It is a curious 
fact that just across the sea from Egypt, in Greece, general 
paralysis is very common. The doctor thinks the Cairo 
asylum would be a good school for the study of craniometry 
and racial characteristics. Among the patients he saw there 
were Egyptians, Copts, Nubians, Soudanese, Abyssinians, 
Turks, Greeks, Syrians, Circassians, Jews and Bedouins. — 
Med Record, May 21, 1892.) 



Persecution al Delusions Cured by Suggestion in the 
Waking State. — Dr. Andrieu {Revue d. V Hypnotism, May, 
1892) reports the case of an officer who imagined that one 
of his colleagues had hypnotized him and caused him to 
commit certain grotesque acts. Andrieu, finding the sub- 
ject not hypnotizable, suggested to him in the waking state 
that he was not hypnotizable, whereupon the notions disap- 
peared. In all probability these delusions remain in abey- 
ance but will take another form. 

J. G. KIERNAN. 

Insomnia in an Infant. — Dr. C. H. Hughes reports the 
case of a five weeks infant which lay awake with eyes 
wide open, gazing about in placid contentment throughout 
the night unless sleep were induced by hypnotics. This 
insomnia continued for five weeks, when it became a tran- 



108 REVIEWS, NEW BOOKS, ETC. [Sept., 

quil sleeper. Sleep was induced by five-grain doses of bro- 
mide of sodium combined with three-grain doses of chloral. 
The doctor concludes from this case that the exhaustion 
theory of sleep is not tenable. This infant slept in the be- 
ginning of its life but became sleepless after a period of rest 
and without excitation provocative of insomnia. He believes 
the insomnia was due to inherent instability of the nerve 
tissue. — (Alienist and Neurologist, July, 1892.) 



REVIEWS, NEW BOOKS, ETC. 



A Dictionary of Psychological Medicine, giving the 
Definition, Etymology and Synonyms of the Terms used in 
Medical Psychology, with the Symptoms, Treatment and 
Pathology of Insanity, and the Law of Lunacy in Great 
Britain and Ireland. Edited by D. Hack Tuke, M. D.,LL. D., 
Examiner in Mental Physiology in the University of Lon- 
don, Lecturer on Psychological Medicine at the Charing 
Cross Hospital Medical School, Co-editor of the Journal of 
Mental Science. P. Blackiston, Son & Co., 1012 Walnut St., 
Philadelphia, Pa. 

This work, long promised, has just appeared, and we 
think it will more than fulfill the most sanguine expecta- 
tions. In fact, it is safe to say that this is the most remark- 
able work upon the subject of psychological medicine which 
has ever been issued. Everything is considered fully, 
though briefly, as is proper in such a work, and if any- 
thing has been omitted we have not yet found it. This is 
a work that will be interesting alike to the specialist and to 
the general practitioner. To the specialist, because it con- 
tains in a brief form all the principal facts with which he 
has to deal ; to the general practitioner because it gives 
him in a comprehensive shape an insight into the vast 
knowledge of the specialist. The first volume opens with 
an historical sketch of the insane by Dr. Tuke, the editor. 
This chapter furnishes a bird's-eye view of the subject, and 
is itself worth the price of the volume. Among the 
many and noted contributors to the work are: Clifford 
T. Allbutt, M. D., Benj. Ball, M. D., Thos. Barlow, M. D., 
Fletcher Beach, M. B., C. E. Beevor, M. D., F. G. Blandford, 
M. D., Alex. Bruce, M. D., Thos. Buzzard, M. D., John B. 
Chapin, M. D.; J. M. Charcot, M. D., Sir Andrew Clark, M. 



1892.] REVIEWS, NEW BOOKS, ETC. 109 

D., T. S. Clouston, M. D., Edw. Cowles, M. D., H. H. Don- 
aldson, Ph. D., Pliny Earle, M. D., Victor Horsley, Joseph 
Jastrow, Ph. D., M. Legrain, M. D., Chas. Mercier, M. B., 
Wm. Orange, M. D., Th. Ribot, James Sully, Aug. Tam- 
burini, M. D., D. Yellowlees, M. D. No extended review 
would do justice to this work. We observe that not only 
those subjects that immediately relate to psychological 
medicine are discussed, but all those that by any means are 
indirectly related to it. For instance, we observe the follow- 
ing: Therino-ansesthesia; thyroid gland in relation to men- 
tal disease; ticklishness, and the phenomena of tickling; gall 
stones in the insane; salivation; neurasthenia; neuralgia; 
night terrors of children; etc., etc. The volumes contain 
articles on the insane in the various countries, and a full 
account of the development and organization of insane in- 
stitutions everywhere and their present condition. We pre- 
dict for this work a large sale in the United States. It is 
a library in itself. In practice it is just the volume that 
every progressive practitioner should have. He will find 
almost every question that may arise in regard to psychology 
answered in this volume, and whether it be in regard to the 
symptoms or treatment of disease, or to definition of terms 
of the physician in dealing with the insane, or to the 
legal responsibility or the legal rights of the in- 
sane, he will find these and kindred questions fully 
discussed and explained. We congratulate Dr. Tuke upon 
the successful completion of this great enterprise, which 
will deservedly add to his already great fame. 

Griessinger'sPathologie undTherapie der Psychischen 
Krankheiten fur Aerzte und Studirende. Fuenfte Auf- 
lage, gaenzlich umgearbeitet und erweitert von Dr. Willi- 
bald Levinstein-Schlegel, Dirigirender Arzt der Heil- und 
Pflegeanstalt "Maison de Sante" Schoenberg-Berlin W. 
Mit vier Abbildungen und einer Figurentafel. 1,100 pp. 
Aug. Hirschwald, Berlin, 1892. The name and works 
of the celebrated and epoch-making alienist, Griesinger, are 
well known to every psychiater. But as time rolled on his 
work became, though a master work, antiquated in some of 
the chapters and behind the times in others. The re- 
viser has sought to fill in these defects and repair the 
ravages of time to bring it down to the requirements of a 
modern work upon this subject. This task the reviser is 
abundantly able to fill, he being the warm and close friend 



110 REVIEWS, NEW BOOKS, ETC. [Sept., 

of the genial author. The holes and weak places of the 
edifices are filled in, wherever a defect was perceptible 
it was remedied, and the whole covered with a fresh 
and bright dressing. The noble columns of the original 
remain untouched. The original text, in its classic and beau- 
tiful form, is still the same, yet rnany chapters required to 
be rewritten and additions made in order to keep the work 
in touch with the advances of modern psychiatry and the 
views of to-day. The literature, up to the middle of 1891, 
has been used as much as possible, and from this period 
only the most important text books were considered for lack 
of time and space. The basis of the revision was formed by 
the text books of modern psychiatry, at the head of 
which stand those of v. KrafTt-Ebing, Schuele, Arndt, Em- 
minghaus, Kraepelin, as well as the works of Salgo, 
Savage-Knecht, Meynert, Fuerstner, Wernicke, Sander, 
Jolly, etc. It was not the intention of the author to give 
psychiatry in a new light, but to bring the doctrines 
nearer to practical use. To Kahlbaum is due the credit 
of building up a new classification of mental dis- 
eases according to these teachings. That which was taken 
from the work is scarcely to be noticed. The genial spirit 
of the writer and his soaring diction still remain as in the 
original work. The reviser has indeed ably succeeded in 
his undertaking, for the book is remarkably complete, full 
of copious notes and additions, and one to which one may 
turn with great satisfaction. Histories of cases and striking 
examples are to be found on every page. Every state is 
treated of even into its smallest details. 

F. H. PRITCHARD. 

Tafeln zur Orientirung an der GEHIRNOBERFL.ECHE 
des Lebenden Menchen bei Chirurgischen Operationen 
und klinischen Vorlesungen. — Von Professor Dr. Albert 
Adamkiewicz (Cracow, Poland) ; mit Deutschen, Fran- 
zoesischen und Englischen Text. Vienna and Leipsic. Wil- 
helm Braumueller, 1892. This atlas consists of four very 
good plates showing the distribution of the cerebral vessels, 
the situation of the convolutions, sulci, sutures, etc. The 
plates are colored and life size, the cerebral vessels being 
distinct and well portrayed. The first gives a front view of 
the brain, the skull cap being removed in one half by a 
section over the eyes and through the vertex. The second 
presents a side view (left) of the cerebrum and cerebellum, 
the meninges being removed. The third exposes the occi- 



1892.] REVIEWS, NEW BOOKS, ETC. Ill 

pital region, while the fourth places the entire vertex, with 
its vessels, lobes and sulci before the eye. All the convolutions 
are marked by differently colored letters in order that they 
may be distinguished by reference to a descriptive table. 
The plates are preceded by two pages of remarks by the 
writer in French, German and English, upon the circulation 
of the blood in the brain, cerebral pressure, etc. The atlas 
will be found of service in all surgical operations upon the 
brain, as well as to the general physician, physiologist and 
alienist. , F> h, pritchard. 

Annual of the Universal Medical Sciences. — A yearly 
report of the Progress of the General Sanitary Sciences 
Throughout the World. Edited by Charles E. Sajous, M. D., 
and Seventy Associate Editors, assisted by Two Hundred 
Corresponding Editors, Collaborators and Correspondents. 
Illustrated with Chromo-Lithographs, Engravings and Maps. 
Volume II, 1892. The F. A. Davis Company, Publishers, 
Philadelphia, New York, Chicago and London. Australian 
Agency, Melbourne, Victoria. This splendid publication 
continues to maintain its reputation. It supplies just what 
every progressive physician needs — a condensed statement of 
the medical progress of the world for the year. The profession 
owes a debt of gratitude to Dr. Sajous for undertaking this 
work. The department of Diseases of the Brain by Dr. 
Landon Carter Gray of New York is especially interesting. 
It is impossible to review this excellent section, as it 
is very much condensed. We observe with pleasure that 
Dr. Gray has utilized some of the illustrations devised by 
Dr. Sanger Brown, for this journal. The department of Dis- 
eases of the Spinal Cord, by Dr. W. R. Birdsall, and the 
department for Peripheral Nervous Diseases and General 
Neuroses, by Dr. Philip Coombs Knapp, are excellent. Dr. 
George H. Rohe, Supt. of the Insane Hospital at Canton ville, 
Md., has written the section on Mental Diseases, and it seems 
to be a thorough resume of the annual literature of the sub- 
ject. We wish again to commend this excellent publication 
to the profession at large. It furnishes a bird's-eye view of 
the world's work and we do not see how any progressive 
physician could be willing to do without it. 



A Manual of Autopsies. — By I. W. Blackburn, M. D., P. 
Blackiston, Son & Co., 1012 Walnut St., Phila., Pa. 

By an oversight, notice of this volume was omitted in the 



112 REVIEWS, NEW BOOKS, ETC. [Sept., 

June number of the Review The volume was prepared in 
response to a request of the Association of Superintendents 
of Insane Hospitals, made at their annual meeting in 1890. 
The author is pathologist to the Government Hospital for 
the Insane at Washington, D. C, having been selected for 
this position by the able superintendent, Dr. W. W. Godding. 
It contains full instructions for making and recording au- 
topsies, not only in relation to the nerves, but to the entire 
body. It also contains a "Table of Weights" of all the organs. 
The remainder of the volume is devoted to methods of pre- 
paring tissues for microscopical examination, which, though 
brief, contains the necessary information. The book is lib- 
erally illustrated and is one which every progressive physi- 
cian should have. Dr. Blackburn is to be congratulated for 
having prepared so excellent a manual, and we hope it will 
have a large sale. 

The National Popular Review, An Illustrated Jour- 
nal of Preventive Medicine and Applied Sociology for 
the Profession and the People. — This is a new periodical 
conducted by Dr. P. C. Remondino, of San Diego, Cal. We 
cannot speak too highly of this publication, which is de- 
voted to Sociology and Preventive Medicine chiefly. It is 
ably and charmingly edited, and furnishes instructive and 
fascinating reading. Every physician ought to subscribe 
for it, and we are sorry for those who will not afford $2.50 
for the amount of valuable material that they will get in this 
journal. Among the notable articles in the August number, 
•'Therapeutical and Moral Effect of Music on Man", and 
"Marriage as a Sociological and Disease Factor", are espe- 
cially worthy of notice. 

The Scalpel. — This is a new periodical conducted in the 
interest of the Chicago College of Physicians and Surgeons. 
It furnishes information concerning the excellent work that 
is being done in that college. The article by Dr. Ohlmacher 
concerning the class work in embryology is particularly 
interesting, and illustrates the important methods of teach- 
ing at the present time. We congratulate the publishers 
of this new journal upon the excellent character of the articles 
in the first number. We have also received an announce- 
ment of the Chicago College of Physicians and Surgeons 
for the coming year. This college, though comparatively 



1892.] REVIEWS, NEW BOOKS, ETC. 113 

youthful, has already taken a high stand, and is for advanced 
medical instruction. The corresponding secretary is Dr. 
Bayard Holmes. 



The Chicago Clinical Review. — This is the first num- 
ber of a new periodical edited by Drs. George Henry Cleve- 
land and Albert I. Boufneur. We notice among the asso- 
ciate editors that there are several alienists, namely; Drs. H. 
M. Lyman, D. R. Brower, Sanger Brown and Archibald 
Church. If the first number of this journal is a sample of 
what it will be in the future we predict that it will be a 
great success. It has a number of original articles and some 
clinical lectures delivered in the hospitals of Chicago by 
physicians in various colleges. We congratulate the editors 
upon the very creditable appearance of their journal and 
wish them all success. 



Dr. Senn has discarded the use of the elastic bandage in 
rendering a limb avascular and empties the blood-vessels by 
simply elevating the member. He believes that the use of 
the elastic bandage is not only superfluous, but in all patho- 
logical conditions, especially, is very dangerous, as its appli- 
cation from the distal part to and over the diseased point to 
the proximal side may force the pathological process into 
the general circulation, which might be the cause of a dis- 
semination of the process. When the limb is rendered avas- 
cular by elevation he interrupts the circulation at once by 
sudden proximal compression. He avoids linear compres- 
sion by using a broad consrtictor, and protects nerve struc- 
tures by using a thick layer of gauze under the constrictor 
when its superficial part cannot be avoided. — Chicago Clini- 
cal Review. 

GERMAN LITERATURE. 



Klemperer. — Grundriss der klinischen Diagnostik. 3d Edi- 
tion. Berlin. A. Hirschwald. 

Transactions of Tenth Internat. Med. Congress, 5 vols. 
Volumes and Sections can be procured separately. Sect. 9. 
Neurology and Psychiatry. Berlin. A. Hirschwald. 

v. Krafft-Ebing. — Psychopathia sexualis. 7th Edition. 
Stuttgart. F. Enke. 



114 REVIEWS, NEW BOOKS, ETC. [Sept., 

Flechsig. — Handbuch der Balneotherapie. 2d Edition. 
Berlin. A. Hirschwald. 

Rosenbaum. — Warum miisseu voir schlafen. Eine neue Theorie 
des Schlafes. Berlin. A. Hirschwald. 

Gowers. — Manual of Diseases of the Nervous System. Author- 
ized German Edition, by Grube. Bonn. F. Cohen. 

Werner. — Die Paranoia. Stuttgart. F. Enke. 

V. Babes and P. Blocq. — Atlas der Pathologischen Histologic 
des Nervensy stems. — By a number of eminent Continental 
Neurologists. Berlin. A. Hirschwald. 

Page. — Railroad Injuries in their Forensic and Clinical Re- 
lations. Authorized Translation by Placzek. Berlin. S. 
Karger. 

Leubuscher und Ziehen. — Klinische Untersuchungen uber 
die Salzsseureabscheidung des Magens bei Geisteskranken. Jena. 
Gustav Fischer. 

Becker. — Anleitung zur Bestimmung der Arbeits- und Er- 
werbsunfahigkeit nach Verletzungen. Berlin. T. C. F. Enslin. 

Edinger. — Zwdlf Vorlesungen uber den Bau der Nervdsen Cen- 
tralorgane. 3d Edition. Leipzig. F. C. W. Vogel. 

Ewald, R. — Physiologische Untersuchungen uber das Endorgan 
des Nervus Octavus. Wiesbaden. J. T. Bergmann. 

Schrenck-Notzing. — Die Suggestions- Therapie bei krankhaf- 
ten Erscheinungen des Geschlechtssinnes. Stuttgart. F. Enke. 

Liebault. — Der kunstliche Schlaf und die ihm'- dhnlichen Zu- 
sUnde. German Edition by 0. Dornbliith. Leipzig and 
Wien. F. Deuticke. 

Sollier. — Der Idiot und der Imbecille. ' Translated from 
the French by Paul Brie. Preface by Pelman. Hamburg. 
H. Voss. 

Lombroso and Laschi. — Der politische Verbrecher und die 
Revolutionen in anthropologischer, juristischer u. staatswissen- 
schaftlicher Beziehung. German Edition by H. Kurella. New 
York. Gustav Stechert. 

Marchand. — Beschreibung dreier Mikrocephalen-Gehimenebst 
Vorstudien zur Anatomie der Mikrocephalie. Leipzig. W. En- 
gelmann. 

Hueckel. — Lehrbuch der Krankheiten des Nervensystems. 
Wien und Leipzig. F. Deuticke. 

Freund. — Schemata zur Eintragung von Sensibilitdtsbefunden. 
Berlin. A. Hirschwald. 

Ringier. — Erfolge des therapeutischen Hypnotismus in der 
Landpraxis. Munich. J. F. Lehmann. 



1892.] REVIEWS, NEW BOOKS, ETC. 115 

Oppenheim. — Die Iraumatischen Neurosen, etc. Second edi- 
tion. Berlin. A. Hirschwald. 

Wilbrandt and Saenger. — TJeber SehsUrungen bei functio- 
nellen Nervenleiden. Leipzig. F. W. C. Vogel. 

Kronthal, P. — Schnitte durch das centrale Nervensystem des 
Menschen. Berlin. Speyer and Peters. 

Arbeiten aus der psychiatrischen Klinik zu Breslau. I. Das 
Hemispharenmark des menschlichen Grosshims. 1. Der Hinter- 
hauptslappen. By Dr. Heinrich Sachs, with a preface by 
Prof. Wernicke. Leipzig. George Thieme. 

Fleiner. — TJeber den heutigen Stand der Lehre von der Addi- 
son' schen Krankheit. (Volkmann's Sammlung Klin. Vortr. 
Neue Folge, No. 38.) Leipzig. Breitkopf u. Haertel. 

D. Ferrier. — Vorlesungen uber Hirnlocalisation. Translated 
by Weiss. Wien. F. Deuticke. 

Th. Kirchhofp. — Lehrbuch der Psychiatric Wien. Fr. 
Deuticke. 

Bel/dan. — TJeber die Trunksucht u. Versuche Hirer Behand- 
lung mit Strychnin. Jena. G. Fischer. 

M. Bernhardt. — TJeber Franklin' sche oder Spannungsstrdme 
vom elektrodiagnostischen Standpunkt. (Volkmann's Samm. 
Klin. Vortr. Neue Folge, No. 41.) Leipzig. Breitkopf u. 
Haertel. 

W.Waldeyer. — TJeber einige neue Forschungen im Gebiete 
der Anatomie des Gentralnervensystems. Leipzig. G. Thieme. 

H. Bernheim. — Neue Studien uber Hypnotismus, Suggestion 
u. Psychotherapie. Translated by S. Freud. Wien. F. Deu- 
ticke. 

Moll. — 1st die Electrotherapie eine wissenschaftliche Heilme- 
thodef Berliner Klinik, No. 41. Berlin. Fischer's Medic. 
Buchhandlung. 

PAMPHLETS AND REPRINTS. 



Sulphide of Calcium, or Calx Sulphurata in Tonsillitis. — 
By Frank P. Norbury, M. D. 

Epilepsy. — Norbury. 

A Case of Abscess of the Temporo-Sphenoidal Lobe, and 
of the Middle Lobe of the Cerebellum. — Norbury. 

Athetosis Bilateralis. — Norbury. 

Practical Cerebral Localization. — Norbury. 

On Certain Peculiarities of the Knee-Jerks in Sleep in a 
Case of Terminal Dementia. — By William Noyes, M. D. 



116 PAMPHLETS AND REPRINTS. [Sept., 

Clinical Lecture Delivered at the Second Annual Meeting 
of the Association of Military Surgeons of the U. S. — Bv 
N. Senn, M. D. 

Report of an Operation for Removal of the Gasserian 
Ganglion. — By Emory Lanphear. 

Expert Witnesses.— By J. T. Eskridge, M. D. 

Kidney Disease and Insanity. — By George T. Tuttle, 
M. D. 

Temperament. — By David W. Yandell, M. D. 

A New Operation for the Speedy Ripening of Immature 
Cataracts. — By Boerne Bettman, M. D. 

Concealed Pregnancy: Its Relation to Abdominal Sur- 
gery. — By Albert Vander Veer, M. D. 

Old and New Ideas With Regard to the Work and the 
Organization of Institutions for the Insane. — By Richard 
Dewey, M. D. 

Fiftieth Annual Announcement of The Rush Medical 
College, Chicago, for 1892-3. 

University of Pennsylvania : Catalogue and Announce- 
ment for Session 1892. 

Northwestern University, Chicago 111. : Circular of Infor- 
mation for 1892-93. 

Columbia College, New York : Circular of Information, 
1892-93. 

College of Physicians and Surgeons, Chicago: Circular. 
P. F. Pettibone & Co., Chicago, publishers. 

The Johns Hopkins Hospital, Baltimore. Lectures, 
Courses of Practical Instruction and Clinics for Graduates 
in Medicine, 1892-93. 

Financial Statement of the Minnesota State Correctional 
and Charitable Institution from August to April, 1892. 

Forty-ninth Annual Report of the Utica State Hospital at 
Utica, for the Year Ending Sept. 30, 1891. Jas. B. Lyon, 
State Printer, Albany. 

Seventy-eighth Annual Report of the Trustees of the 
Massachusetts General Hospital and McLean Asylum, 1891. 
L. Barta & Co., Printers, 148 High street, Boston. 

Annual Report of the Milwaukee County Hospital for 
the Year Ending Dec. 31, 1891. Ed. Keogh, Printer, 386 
and 388 Broadway, Milwaukee, Wis. 

Annual Report for the Year Ending Feb. 28, 1892, of 
St. Luke's Hospital, St. Paul, Minn. 

Catalogue for the year 1891-92, and Announcement for 



1892.] PAMPHLETS AND REPRINTS. 117 

the Year 1892-93 of The College of Medicine and Surgery, 
University of Minnesota. 

Forty-sixth Annual Report of Starling Medical College, 
Columbus, 0. Journal-Gazette Printing House. 

Annual Announcement and Catalogue of the Baltimore 
Med. College. Printed by King Bros., 123 E. Baltimore 
St., Baltimore, Md. 

Hospital Bulletin of the Second Minnesota Hospital for 
Insane. Press of The Record and Union, Rochester, Minn. 



MISCELLANEOUS. 



PRIZE ESSAYS — ON THE ACTION OF ALCOHOL AND ITS VALUE 

IN DISEASE. 

The American Medical Temperance Association, through 
the kindness of J. H. Kellogg, M. D., of Battle Creek, Mich., 
offers the following prizes: 

1st. One hundred dollars for the best essay " On the Physical 
Action of Alcohol, based on Original Research and Experiment." 

2d. One hundred dollars for the best essay "On the Non- 
Alcoholic Treatment of Disease." 

These essays must be sent to the Secretary of the Commit- 
tee, Dr. Crothers, Hartford, Conn., on or before May 1, 1893. 
They should be in type-writing, with the author's name in 
a sealed envelope, with motto to distinguish it. The report 
of the committee will be announced at the annual meeting 
at Milwaukee, Wis., in June, 1893, and the successful essays 
read. 

These essays will be the property of the association and 
will be published at the discretion of the committee. All 
essays are to be scientific, and without restrictions as to 
length, and limited to physicians of this country. 
Address all inquiries to 

T. D. Crothers, M. D., 
Secretary of Committee, 

Hartford, Conn. 

Antiseptics and Disinfectants. — The prevention of dis- 
ease is the unselfish mission of the modern physician. 
Antiseptics and disinfectants to-day occupy the first place in 
medical and surgical practice. Dilute solutions of acids 
have been strongly commended as preventive of cholera. 



118 MISCELLANEOUS. [Sept., 

The Liquid Acid Phosphate is an efficient agent in securing 
the desired condition of acidity. Copper Arsenite Tablet 
Triturates, 1-100 and 1-5000 grain, have been extensively 
and successfully used in dysentery and diarrhceal disorders 
and are indicated in cholera, both for specific action in con- 
trolling intestinal secretion and for relieving the profound 
ansemia. Eucalyptus and Thymol Antiseptic is 
adapted for use as an antiseptic internally, exter- 
nally, hypodermically, as a douche, a spray, by atomi- 
zation, and as a deodorant. Its application in surgery is 
unlimited. It is an excellent dressing for wounds. It com- 
bines the antiseptic virtues of benzoic acid, boric acid, oil of 
peppermint, oil eucalyptus, oil wintergreen, oil thyme and 
thymol. Tablets of Yellow Oxide of Mercury, containing 
two hundredths of a grain of the oxide, are a valuable pro- 
phylactic against dysentery and enteric fever. They prevent 
fermentation and putrefaction, and render aseptic the ali- 
mentary tract. Chloranodyne is a combination of anodynes, 
antispasmodics, and carminatives, which has been widely 
employed in gastric and intestinal troubles. It acts very 
happily as an anodyne and as an astringent in cholera, dys- 
entery, diarrhoea and colic. Antiseptic Liquid arrests de- 
composition and destroys noxious gases that arise from or- 
ganic matter in sewers and elsewhere, and may be used in 
cellars, barns, outhouses and the sick-room. Antiseptic 
Tablets are convenient for the extemporaneous preparation 
of antiseptic solutions of definite strength of mercuric 
bichloride for disinfectant purposes and for antiseptic sprays. 
Disinfectant Powder possesses in a high degree disinfectant, 
absorbant and antiseptic properties. It is admirably 
adapted for the disinfection of excreta in cholera, yellow 
fever and typhoid fever. Sulphur Bricks are effectual in 
the fumigation and disinfecting of rooms after infectious 
diseases. Ethereal Antiseptic Soap (Johnson's) was devised 
by an experienced nurse in the surgical clinic of the Jef- 
ferson Medical College. Its marvelous cleansing powers 
make it a valuable adjunct to the armamentarium of the 
physician and surgeon. Mercuric Chloride can be dissolved 
in it in ordinary proportions. Parke, Davis & Co. will be 
pleased to forward, on request, any information desired con- 
cerning these products. 



Vol. III. DECEMBER 1892. No. 2. 



THE REVIEW 



OF 



Insanity # Nervous Disease 



A Quarterly Compendium of the Current Literature 
of Neurology and Psychiatry. 



edited by 

JAMES H. McBRIDE, M. D., 

milwaukee, wis. 

associate editors: 

Landon Carter Gray, ML D., New York ; C. K. Mills, ML D., Philadelphia ; 
EUGENE RTGGS, M. D., St. Paul, Minn. ; W. A. JONES, M. D., Minneap- 
olis, Minn.; H. M. BANNISTER. M. D., Hampton, Ct.: D. R. 
BROWER, M. D., H. M. LYXAN, M. D., J. G. KIERNAN, ML. D., 

Archibald Church, M. D., Sanger Brown, M. D., 
S. Y. Cleyenger, M. D., Chicago. 



$2,00 PER YEAR. SINGLE NUMBERS, 50c 



MILWAUKEE : 

RIVERSIDE PRINTING CO., PRINTERS, 

1892. 



INDEX. 



Original Article — Itching of Central Origin, or 

Brain Itch, 121-132 

By L. BREMEK, M. D. 



JN EUROLOGICAL — 

Anatomy and Physiology, ... 


134-140 


Pathology and Symptomatology, 


140-171 


Therapeutics, 


171-187 


Surgery and Traumatic Neuroses, - . 


187-206 


Psychological — 




Pathology and Symptomatology, - 


206-226 


Editorial Notes and Comments, 


227-233 


Correspondence, - - 


233-234 


Reviews, New Books, Etc., ... 


234-246 


Pamphlets and Reprints, 


246-249 


Miscellaneous, 


249-251 



The Review 



OF 



Insanity and Nervous Disease. 



DECEMBER, 1892. 



ITCHING OF CENTRAL ORIGIN, OR BRAIN ITCH. 



By Dr. L. Bremer, St. Louis. 



Itching is so frequently observed as a complication in 
nervous and mental diseases that it deserves, in my opinion, 
a more than passing notice. Dermatologists have long since 
recognized the existence of what they have collectively 
styled neuroses of the skin, or dermatoses, but, to my knowl- 
edge, they have failed to make a clear distinction between 
the peripheral and the central forms of these affections. 

Before approaching the subject-matter itself, a brief retro- 
spect of the accepted neurophysiological notions regarding 
the various qualities of sensations I think to be in order. 
The brain, as is now weil established, is primarily and 
essentially a sensitive, and secondarily, a reflex organ. The 
various qualities of sensation coming to this receiving and 
perceiving organ from the outer world are caught up by the 
cortical pyramidal cells, whose protoplasmic processes are 
comparable to tentacles, in the language of Meynert. 

Within the cells are stored up the impressions thus 
gathered as memory images, which are of a sensorial, sen- 
sory, or (by reflex) motor character. The several qualities 
of such impressions are not, as is well understood, scattered 
promiscuously over the brain, but there are distinct and cir- 
cumscribed patches of the cortical surface where memory 
images of the same quality are stored up. Thus there are, 
in addition to the well-known motor and sensorial areas of 



1 22 itching of central origin. [December, 

vision and audition, others, where memory images of com- 
mon sensation, especially such as originate in the skin and 
neighboring mucous membranes, are stored, although 
the exact location of these centers is still a matter of dispute. 

Now, it cannot be presumed that there are special nerve 
fibers gathering up and conveying itching impressions from 
the periphery to the cortex, the fact being reasonably well 
established that itching is simply a perverted function of 
the nerves of common sensation, the same as pain, pricking, 
formication, etc. Unfortunately, as remarked before, the 
localization of common (and hence modified and perverted) 
sensation is still a matter of doubt. The most probable of 
all hypotheses at present, is that the sensory area of the 
several parts of the body is around or near the respective 
motor centers, and I claim that as there is a central or 
cerebral pain, a proposition which I shall discuss at length 
later on, so does there exist a central or cerebral pruritus. 

In order, however, to gain an adequate conception of the 
central, it will be necessary to briefly consider the mechan- 
ism of peripheral itching, or rather those dermatoses in 
which a peripheral nerve irritation is the pathogenetic 
factor of this symptom. 

The anatomical seat of peripheral pruritus has been laid 
by almost all writers on the subject in the touch corpuscles. 
That the seat of this sensation, like all the others, is some- 
where in the true skin and not in any of the underlying 
tissues there can be no manner of doubt, because the 
experiments of Weber have settled this matter definitely. 
But, to my mind, it is highly improbable that the tactile 
bodies should be the organs in which and through which 
the sensation of itching should originate, they being in our 
days generally regarded as sensory terminal organs by 
which pressure and weight are estimated. It is much more 
probable that the free end-filaments in the epithelial layer 
of the skin should be regarded as the seat of disturbance in 
peripheral pruritus. That it does arise here under certain 



1892.] BY DR. L. BREMER. 123 

conditions is proven by the familiar example of itching in 
granulating wounds. The granulations are devoid of sen- 
sation as long as they are not yet covered with epithelium, 
but, as soon as the regenerative process has begun and a 
slight film of epithelial layer (together with newly formed 
nerve filaments) spreads over the granulations, the pro- 
cess of repair is generally announced by an itching sen- 
sation, and so far as my observation goes, this itching is 
not only felt in the neighborhood of the defect but is also 
located by the patient in the newly-forming epithelial cover, 
which would go to show that the growth of the delicate 
nerve-filaments that supply the epithelial layers with sensa- 
tion keeps equal pace with the growth of the latter, and 
that in them resides, besides the faculty of general sensation, 
also that of itching. Another reason why the touch-cor- 
puscles are unlikely to be the organs through which itch- 
ing is felt, is the fact that those places where these bodies 
are known to abound most, in the tips of the fingers, toes, 
and in the lips, etc., are by no means the seat of predilection 
for pruritus, but are, on the contrary, rather exempt from- it. 

Returning to the subject of peripheral dermatoses we may 
legitimately set down herpes zoster as a type of those 
neuropathic skin affections for which a well defined topo- 
graphical and anatomical basis exists. The several itching 
skin diseases which before Hebra were comprised as prurigo, 
may also, in a sense, be regarded as peripheral affections of 
the nerves of common sensations, the mechanism of their 
production being, according to some, the pressure on the 
terminal sensory filaments by an exudation (prurigo papule) 
or, as Anspitz assumes, a tonic spasm of the smooth muscle 
fibers in the skin, the arrectores pilorum. If the latter ex- 
planation were admissible, there would be a combined 
neurosis of a sensory and motor character. It is very ques- 
tionable, though, whether in such cases there exists primarily 
such a spastic contraction entailing the hypertrophy of the 
arrectores which is observed in the latter stages of prurigo. 



124 itching of central origin. [December, 

The same mechanism, that of compression, of the sensory 
nerve-endings is assumed by Unna to underlie the itching 
in urticaria. This observer thinks that the wheals are due 
to an elastic oedema caused by an obstruction of the efferent 
lymph channels, arising under the command of the nervous 
system. A congestion, thought to be due to a contraction 
of the veins, is, in his opinion, responsible for this obstruc- 
tion. 1 

The theory of obstruction and compression as explaining 
the sensation of itching is thought to be strengthened by 
the experiment of an hypodermic injection of water under 
the skin. This in some persons causes itching, a fact, how- 
ever, which admits of other interpretations than that of 
compression, notably that of chemical irritation. The irri- 
tating action on the tissues of water, especially distilled 
water, is well established. It is indeed more probable that 
in all, or nearly all cases of itching, there is an irritating or 
toxic element in the fluids surrounding the terminal nerve 
filaments. This is notably the case in eczematous affections. 

Hebra referred all itching sensations to a slowing of the 
blood-current in the capillaries of the skin because the pro- 
duction of an hyperemia, with an attending acceleration of 
circulation, but especially a local depletion produced by in- 
juries of the vessels due to scratching, alleviates or stops 
itching. 

Supposing that an hyperaemia and a consequent retarda- 
tion of the blood's flow were the cause of itching, the con- 
gestion could be only a venous one, and in this case, too, the 
toxic origin would suggest itself, the waste products, or, 

1. Itis very difficult and, to my thinking, physiologically impossible to con- 
ceive, that a separate, or even a preponderating spastic contraction of the veins 
should take place under the command of the nervous system, i. e. the vaso-motor 
center or centers. Admitting that the veins possess a tonus similar, though, of 
course, much weaker than the arteries, a proposition which is denied by some 
physiologists, it is inconceivable how a separate contraction could arise; the 
stimulation of the vaso-motor centers, if it does cause a contraction at all, will do 
so primarily and chiefly in the arteries, the veins, owing to their feeble muscular 
coat and an insignificant supply of nerves, participating in the contraction in a 
subordinate degree. It may be remarked here, that the statement generally met 
with in books on general anatomy or physiology, viz; that only the larger veins 
are accompanied by nerves, is incorrect. All blood-vessels, even the capillaries 
are provided with nerves. 



1892.] BY DR. L. BREMER. 125 

possibly elements of a specific irritating character, giving 
rise to the itching. 

This toxic influence of the fluids bathing the sensory 
nerve terminations as an essential factor in itching seems to 
be beyond doubt in certain dyscrasise (jaundice, Bright's 
disease, diabetes, general carcinomatosis, etc.). But it is not 
in all patients affected with these diseases that we find itch- 
ing as a complication ; in the most intense forms of icterus, 
e. g. in which the skin is saturated with bile-pigment, and 
where we would expect the most intense itching, if it were 
true that this is caused by the deposition and consequent 
irritation of the coloring principle of the bile, pruritus is 
sometimes utterly absent. This would point to the neces- 
sity either of admitting that a poison is at work whose 
nature we ignore, or of calling to our aid in the understanding 
of the phenomenon once more the makeshift, " individual 
predisposition," however distasteful this may be to the mind 
of the pathologist. 

The admittance of such pruritic predisposition, an essen- 
tial pruritus, or itching independent of either a demonstrable 
or molecular skin affection, leads up to the main question, 
the subject matter of the present article, central or cerebral 
itch. 

As remarked above, the question of the possibility of a 
central origin of pain is a very old one and seemed up to a 
short time ago in dispute. The current opinion of neuro- 
pathologists on this subject seemed to be that, since lesions 
in the substance of the brain or spinal cord itself rarely 
were accompanied with painful sensations, whereas morbid 
conditions of the covering membranes of those organs were 
almost always attended by pain, the cerebro-spinal substance 
itself must needs be devoid of feeling. 

Moreover, the unanimous verdict of the physiological ex- 
periments on the central nervous system was that the nervous 
substance itself lacked absolutely any trace of sensibility. Since 
the sort of experiment seemed in a measure to have deter- 
mined and settled the question, the clinical neurologist 



126 itching of central origin. [December, 

acquiesced in the result, though inadequate and far from 
decisive, of physiological investigation. But the observa- 
tions made on experiments performed by nature, i. e. disease, 
did not tally in many instances with notions based on phy- 
siology. Edinger 1 was, to the writer's mind, the first to 
demonstrate on anatomical findings the central origin of 
pain in a certain class of cases. He cites a case of Greiff, 
in which there were, in addition to a left-sided paresis and 
chorea, hyperesthesia and tearing pains in the left arm and 
some in the left leg. The principal post-mortem finding 
consisted in softened foci in the right thalamus. Edinger's 
own case, the only one in which an accurate study of clinical 
symptoms is followed by a minute and scrupulously con- 
ducted microscopical examination, showed during life, as a 
result of an apopleptic attack, paralysis of the right arm 
and leg, accompanied later on by slight athetosis, and at all 
times excruciating pains, in consequence of which the patient 
suicided. The autopsy revealed a softened focus in the ex- 
ternal nucleus of the left thalamus opt. and in a small por- 
tion of the pulvinar. There was also descending degenera- 
tion of the lemniscus. Edinger arrives at the conclusion 
that hyperesthesia and pain were produced, not by an 
involvement in the pathological process of the caudal por- 
tion of the internal capsule (that part of it which corres- 
ponds to about the middle third of the thalamus, and which 
is the universally recognized sensory tract, giving rise to 
peripheral pain, similarly to the production of pain by irri- 
tation of a nerve in any part of its course, the painful sen- 
sations being projected to the sensory end-organs of the 
periphery). Had the sensory capsular tract been pathologic- 
ally changed") there would have been an anaesthesia, instead 
of an hyperesthesia. There is, then, no doubt in Edinger's 
mind (and a careful perusal of the article has convinced 
the writer of the correctness of his conclusion) that there 
may be pain of central origin, and that it is reasonable to 

1. Edinger. Giebt es central entstehende Schmerzen? Deutsche Zeitschr. f. 
Nervenheilk. H. 3 und 4. 



1892.] BY DR. L. BREMER. 127 

infer from the anatomical findings in his case that even a 
cortical pain exists. From purely clinical observation it 
would seem that the latter proposition is very plausible and 
almost self-evident; for how could the pain of the hypo- 
chondriac or the hysterical, or that of hypnotic suggestion be 
understood or explained, unless the theory of cortical origin 
be invoked ? The aura, too, in some cases of " cortical " 
epilepsy can not be explained on any other ground than 
that of a projection of a cortical irritation on a correspond- 
ing area of the skin. 

The abnormal sensation constituting the aura may be an 
itching, instead of pain, burning, pricking, constriction, 
etc. Assuming that all epilepsies are cortical in origin, a 
theory which is constantly gaining ground, this local itching 
representing an epileptic aura would also furnish an irrefut- 
able proof of the cerebral resp. cortical origin of itching. 

I have seen more than one neurasthenic person, who, when 
reading, experienced an intense itching in some part of the 
scalp, by preference on top of the head ; in one case this 
itching was often substituted by a pricking, at others a 
painful feeling showing the intimate relationship, if not, at 
bottom, the qualitative identity of these sensations. 1 

Persons afflicted with this troublesome affection are always 
neurotic or psychopaths. Most of them can by sheer will- 
power produce itching in the parts usually and principally 
attacked by concentrating their attention on those spots, as 
Dr. John Hunter, a neurasthenic par excellence, could cause a 
pain in his big toe by thinking of the gout as invading that 
member. 2 

Again, it is a matter of common observation that some 
persons on hearing about, or seeing vermin, will begin to 



1. That itching- may, and probably is, a modified, i, e. lesser pain, seems to me a 
justifiable conclusion, derivable from the every day observation that the induc- 
tion of pain, by scratching, for example, but also by whipping or otherwise in- 
juring the affected parts, will lessen or stop it. 

2. This effect of the mind on the periphery of the body is seen in all itching af- 
fectious with demonstrable changes, e. g. eczema, prurigo, urticaria. There is 
the often emphasized vicious circle in these maladies. The peripheral sensation 
impresses the cortical cells in such a manner that under the influence of some 
exciting cause these morbidly impressed cells will cause itching even after the 
anatomical changes originally responsible for it, have ceased to exist. 



128 itching of central origin. [December, 

scratch themselves to relieve itching. This is evidently- 
brought about by an association process in the hemispheres. 
The central origin of pruritus is in such cases beyond 
doubt. It has, furthermore, been often observed that 
psychical pain occasioned, for instance, by the death of 
friends, relatives or parents, is attended by localized or 
general, more or less intense itching. In fact, pruritus is a 
frequent complication in mental disease, that taxes the 
ingenuity and, unfortunately, often baffles the efforts to 
relieve, of the psychiater. 

To my mind, it is quite evident that in such cases an 
abnormal nutritive and functional process having its seat in 
the cortex is projected from this organ to the skin, or such 
areas of it which correspond to the several cortical areas 
innervating them. If we look for an analogue, this most 
powerful lever to our understanding, the central excitations 
of the sensorial organs (of vision, hearing, smell and taste) 
readily present themselves for comparison. 

Not only the subcortical centers of perception, but also the 
higher cortical ones of apperception 1 are capable to project 
to the respective peripheral sensorial organs (eye, ear, nose, 
tongue) the various sensorial qualities ; the movement is in 
an inverse direction, i. e. from the center to the periphery. 

Whilst I have often witnessed pruritus accompanying 
psychoses, principally melancholia, I have seen two cases 
in which this symptom preceded the outbreak of the men- 
tal trouble and disappeared as suddenly as it had come on 
with the first manifestation of the mental derangement. 
One of these cases was the wife of a physician. In the 

1 The term "apperception" is not frequently used in the psychiatric language 
of the English speaking nations. A short definition is, therefore, perhaps not out 
of order in this place . Perception of peripheral sensorial impressions takes place 
in the several subcortical centers, whilst apperception, i. e. the correct interpre- 
tation, fixation and adjustment of the value and import of the impression per- 
ceived, is effected in the organ cf association, the cortex. Thus, the sound of a 
bell is perceived as a sound pure and simple in the subcortical centers, but the 
apperception of this sound, its meaning, direct and implied, is realized by the 
higher associative process in the cortex, which consists in awaking the functional 
activity of a set of cortical ganglionic cells in which certain memory images are 
stored up. By irritative processes these centers, the subcortical as well as the 
cortical, may be rendered functionally active ; in the first case sounds will be 
heard; in the second, words or sentences. This constitutes the mechanism of 
hallucinations in the insane. 



1892.] BY DR. L. BREMER. 129 

eighth month of pregnancy she suddenly was attacked by 
furious itching, involving the whole skin and all the muc- 
ous membranes accessible to the air. In this state she was 
delivered, when the pruritus stopped as suddenly as it had 
made its appearance, a stuporous melancholia setting in 
instead. In this state she did not recognize her children. 
She made a complete recovery. 

The other was that of a girl 19 years of age, coming of 
neurotic stock. She woke up one night, suddenly, with the 
most intense itching. This lasted for several weeks without 
there being the slightest trace of a skin affection, except a 
secondary eczema around the genitals, which formed one of 
the chief foci of the pruritus. Excessive onanism was the 
result. About two weeks after the onset she became pro- 
foundly melancholic, when suddenly the pruritus ceased. 
Though often in a stuporous condition, she believed herself 
watched and persecuted and had suicidal ideas. Repeatedly 
she was taken with pruritus in the course of her mental 
malady, when she would almost, but not quite, recover her 
reason. Finally she recovered her mind after a severe 
attack of pruritus, which lasted for days and in the course 
of several weeks subsided entirely. 

In neurasthenia and hysteria, pruritus, local and general, 
is not unfrequently a troublesome complication. In these 
maladies it is also undoubtedly a brain itch, and not a periph- 
eral affection, that we have to deal with. For the mere 
thought of itching, or the fixing of the attention on any 
particular spot of the body is capable of giving rise to in- 
tense itching. In the case of a lady who suffered from the 
gastro-intestinal type of neurasthenia, an insignificant fright, 
a shock, but also a pleasurable emotion passing a certain 
limit, even a bruise or a slight blow on any part of the body, 
would invariably be followed, besides a copious fetid dis- 
charge from the bowels and a quivering of the abdominal 
walls, by an itching in various parts of the body which in 
proportion to the severity of the shock became more or less 
general and intense. 



130 itching of central origin. [December, 

There are some unfortunate neurasthenic women in whom 
central pruritus, localizing in or about the vaginal orifice, 
constitutes the main and all-overtowering symptom. They 
are invariably treated by gynaecologists who almost as invari- 
ably will set down the trouble a "reflex" neurosis, having its 
origin in one or the other real, though paltry, more often, 
though, imaginary, pelvic disorder. They are treated locally 
for years until they are wrecks. In the cases which I have 
seen there prevailed in a striking way the rapid shifting of 
sensory disturbances. Either the urethra would itch to an 
intolerable degree, causing for weeks an incessant desire to 
urinate, or, when this symptom grew less, or disappeared, 
the ears, their meatus and surrounding parts would be 
attacked by the itching, or there would be an intolerable 
pruritus in other parts. Of course pruritus is never the 
exclusive symptom in such persons, neuralgias, neurotic 
cedema and paresthesia of varying qualities generally co- 
existing. 

A very serious complication in such unfortunates is onan- 
ism. For pruritus, whether it is localized in and around 
the orifice of the urethra, or at any other part of the 
pudenda, will not remain confined to its chief seat but tend 
to spread. Thus the clitoridian region will be invaded with 
the well-nigh inevitable disastrous consequences. The pru- 
ritus in these cases leads soon to an artificial eczema by 
scratching similar to the eczema of the scrotum, perineum 
and anus in man. These are the cases which so often 
terminate in utter wreckage, physical and mental ; and the 
unwarrantable diagnosis, " neurasthenia, or insanity from 
onanism" is made, when, as a matter of fact, a primary 
central disturbance gave rise to a secondary local manifesta- 
tion (itching) which in its turn led to onanism and its dire 
consequences. The cases of nympho-mania, of which I 
have seen only one, are only secondarily referable to this 
complication ; for there is a brain itch before there arise 
the clitoridian, or pudendal itch. 



1892.] BY DR. L. BREMER. 131 

I have known neurasthenic men to become greatly reduced 
in strength and flesh by the loss of sleep caused by intense 
itching. The places of the attack would change in a most 
capricious manner, the favorite time was generally at night, 
either on going to bed or on awakening early in the morn- 
ing. Most of them could produce the itching voluntarily, 
simply by a mental effort and by fixing their thoughts on a 
particular spot. 

The itching in hysteria is also one of the many trying and 
annoying symptoms of that neurosis and is referable to the 
cortex as its starting point. I have even seen it in cases of 
coarse brain lesions, particularly in one instance of what I 
diagnosed as embolism of the right Sylvian artery. The 
itching was at times intensely severe and withstood all 
palliative treatment. 

The treatment of the kind of pruritus which I have tried 
to elucidate in the above remarks forms a dark and dis- 
couraging chapter in therapy. Dermatologists have ex- 
hausted the resources which therapeutical ingenuity has 
been capable of devising. In all works on skin diseases I 
meet with the advice to send such persons traveling who 
suffer from itching combined with melancholia. 

The practical results have been extremely meagre, perhaps 
on account of the fact that too much attention has been paid 
to the local manifestation of what is really a central trouble. 
But, this proposition being admitted, are the prospects of 
"cerebral" treatment any better ? Does the treatment of the 
cerebral cortex promise more propitious results ? 

The only remedies which suggest themselves are the 
various narcotics which are known to subdue cortical 
irritability. Unfortunately the most reliable of all, opium 
and its alkaloids, is notorious for causing itching sensations 
in neurotic persons, not only at the tip of the nose and the 
adjacent mucous membrane of the nares, but also in other 
parts of the body. So does in my experience cannabis 
Indica, which, in nervous individuals, besides pricking, or 



132 itching of central origin. [December, 

the "pins and needles" sensation and numbness, causes in 
some decided pruritus. 

Many neurasthenics, however, are immediately, and some- 
times permanently relieved by a combined bromide (10 to 
12 grains 3 times a day) and cannabis treatment (J grain of 
the extract as often) provided that other remedies and pro- 
cedures usually employed in the treatment of neurasthenia 
are not neglected. 

In the toxasmic variety the rational treatment would be 
to modify and correct the faulty metabolism of the tissues. 
Here again, the perverted function of the cells could, it is 
reasonable to infer, be reached only through the nerves. 
Of such remedies we have only a slight empirical knowledge 
derived from the action of the alteratives so-called, but what 
their modus operandi is we do not know. 

Nor are we acquainted with any drug which is capable of 
neutralizing supposititious poisonous substances or materials 
which irritate the central or peripheral sensory nerve- 
endings and causing pruritus. 

Of all the remedies recommended for the kind of pruritus 
discussed in the preceding remarks, and, in fact, pruritus of 
any kind and origin, the warm bath with soda and starch 
(a handful of wash-soda and half a pound of starch to an 
ordinary bathtubful of warm water) seems to act better than 
any other remedy which I have tried. At all events, this 
simple measure has given better satisfaction than any other 
in institution treatment, where such cases are notoriously 
often a source of despair both to the patient and physician. 
Even in strictly central pruritus it generally acts well, 
owing, probably, to the sedative effect which the warm bath 
has on the cortex. 



1892.") 133 



TRANSLATORS. 



ITALIAN. 
H. M. BANNISTER, M. D. 

F. H. Pritchard, M. D m Norwalk, Ohio. 

GERMAN. 

G. J. KAUMHEIMER, M. D., MILWAUKEE. 
H. M. BANNISTER, M. D. 

Jos. Kahn, M. D., Milwaukee. 

ROUMANIAN, RUSSIAN, DUTCH, PORTUGUESE, 
SWEDISH, DANISH AND NORWEGIAN. 

F. H. Pritchard, M. D., Norwalk, Ohio. 

FRENCH. 
J. G. KlERNAN, M. D., CHICAGO. 

SPANISH. 

Horace M. Brown, M. D., Milwaukee. 
F. H. Pritchard, M. D., Norwalk, Ohio. 

DUTCH. 
William Sweemer, m. d., Milwaukee. 



134 neurological. [December, 



NEUROLOGICAL. 



ANATOMY AND PHYSIOLOGY. 



Brain and Skull Correllations. — This is the title of 
an article by Dr. S. V. Clevenger in the October number of 
Science. He calls attention to a previous article in which he 
shows that the sulcus of Rolando is placed further back in 
the adult than in the young animal, forming the posterior 
boundary of the frontal lobe, and that the latter, as it in- 
creases in size in proportion to the intelligence, presses back- 
ward the posterior part of the brain. He sums up cranio- 
cerebral peculiarities as follows : " 1. The more erect posi- 
tion tends to move the foramen magnum forward. Increased 
intelligence and erectness are generally, but not invariably, 
associated in animals, so the position of the foramen alone 
as an index has a restricted value. 2. The frontal brain- 
growth is always associated with increased intelligence, and 
this development crowds the sulcus of Rolando farther back 
and pushes the medulla oblongata and pons Varolii into a 
more and more upright position, provided the brain-growth 
is greater than that of the skull, for a roomy skull may 
afford expansion and allow the primitive obliquity of me- 
dulla and occipital bone to persist. 3. The adjustment of 
the skull to its contents is a complex matter, but may be 
better understood by relating cause and effect as acting 
upon both more or less simultaneously, particularly with 
regard to the differences in hardness and developmental 
changes in both. For example, the beaver's skull and brain 
seem to have kept pace together so as to render convolutions 
unnecessary, and the beaver is an intelligent animal. The 
brain of Prof. Leidy was highly convoluted, and appears to 
have been rendered so by his cerebral being greater than 
his skeletal growth, and this would seem to have been 
a family peculiarity, for his brother's brain presented 
a similar appearance of crowded convolutions. 4. When 
a juvenile retreating forehead has gradually been re- 
placed in an adult by a more perpendicular one, through 
education acquired later in life, then the frontal brain may 



1892.] ANATOMY AND PHYSIOLOGY. 135 

have crowded and formed more numerous convolutions and 
fissures in consequence, but the pharynx may not be 
changed from the original inclination. 5. The softer brain 
is likely to undergo more rapid changes than the harder 
skull, either in the evolution of species or the individual, 
and the mere cranial conformation may, or may not, there- 
fore, be an index to brain area and intelligence, and what- 
ever changes may occur in the skull due to brain increase 
have reference more to enabling the brain to find room in 
the cranium, so that a higher forehead may render the 
more erect basi-occipital unnecessary, or vice versa, and 
normal or abnormal growth of brain may raise both osseous 
portions. Some mongrel dogs may inherit a larger brain 
from one parent and smaller brain-case from another, which 
would account for the deep indentations in their skulls, the 
pressure causing them sometimes to suffer from epilepsy 
and other brain derangements ; this disparity is not likely 
to be so great in the offspring of better-mated species. 6. 
Many other matters could be considered, such as centres of 
ossification and cartilaginous persistence between such parts 
as the basilar process and sphenoid, enabling adjustment of 
the pharynx to the changed medulla angle." 



The Physiology of the Cerebellum. Gallerani and 
Borgherini (Revista Sperimentale, XVIII, II, Aug., 1892) from 
their studies on the cerebellum conclude that the cerebellum 
is a nerve centre in intimate relation with co-ordination of 
voluntary movements. Its complete destruction causes per- 
manent ataxia of voluntary movement and marked distur- 
bance in the head and neck. The muscular force is not 
diminished nor is the muscular sense, properly speaking. 
No special functions are localized in the cerebellum. Ac- 
cording to the authors it is a physiological unity, any portion, 
greater or less, of its substance remaining uninjured there 
may be a gradual restoration of its functions whenever the 
remnant preserves the relations which normally exist be- 
tween each part of the cerebellum and the other nervous 
centres. The superficial lesion of the organ, which in ex- 
periments necessarily involves the superior posterior portions, 
has as a constant and permanent result, tremor of the head and 
neck. With the organs of sight and intelligence together the 
animal corrects, in some degree, his own motor disorder by 
avoiding some movements and exercising caution in others. 



136 neurological. [December, 

It applies its intelligence by means of its sight much more 
intensely than in its normal condition. Deprived of sight 
it gives up all attempts at voluntary motion. This explains 
its peculiar attitudes when the eyes are bandaged, and the 
permanent abnormal positions of the limbs. The character 
of the ataxia from cerebellar lesion is similar to that of spinal 
ataxia in man. The vermis has an important part in the 
co-ordination of movements. Its section causes an ataxia 
similar in type but less extended than that due to extirpation 
of the cerebellum. It acts as the commissure and unifies the 
synergic and symmetrical halves in their functions. Its 
want of action in this way after section may be supplied 
by the cerebrum (psychic substitution). The paper of 
Gallerani and Borgherini is followed by a caustic critical 
note by Prof. Luciani with whose recently published 
views they are not in accord, and to which they reply 
in a brief note, stating that they recognize the great 
authority of Luciani, but no less also that of their instructors 
Lussana, Stefani and Alb^rtoni, who have also not accepted 
his views. Their own investigations on the cerebellum, they 
claim, have been in progress for over five years, and while 
their observations may not be absolutely beyond criticism 
they do not feel compelled, out of respect for authority, to 
refrain from their publication. 

H. M. BANNISTER. 



The Decerebrated Dog. — Prof. Goltz has published in 
Pfluger's Archiv, Bd. 51, a series of experiments which seem 
to set aside all our theories of cerebral localization. The 
Wien. Med. Blatt., No. 28, 1892, gives the following abstract 
of this work : Prof. Goltz, of Strassburg, has succeeded in 
keeping alive 3 dogs from which the entire cerebrum had 
been removed with the knife. One animal lived 51 days, 
a second, 92 days, and the third was killed, while in perfect 
health, 18 months afterward. It is to this last animal that 
the succeeding remarks mainly apply. In all three it was 
found that the inter-brain had suffered to a considerable ex- 
tent at the operation. A short time before his death the 
following observations were made on dog No. 3 : He could 
be wakened from a deep sleep by a tactile irritation. If the 
attempt was made to remove him from his cage he became 
angry, resisted, growled, barked (in a normal manner) and 
attempted to bite. When put back he ceaselessly roamed 
around in a circular route, often slipping where the path 



1892.] ANATOMY AND PHYSIOLOGY. 137 

was smooth, but arising without help. When he was hungry 
his movements were especially lively. Any attempt at 
moving his limbs was resisted and corrected with signs of 
displeasure. He never stepped on the back of the foot. If 
placed on a table so that one foot rested on a trap-door he 
did not fall, but removed the limb from the trap. When 
one of his hind limbs was accidentally injured he ran about 
on 3 legs for days, as a normal dog would do. Hearing was 
preserved to some extent as the sound of a trumpet would 
rouse him from sleep. Sight was also present in some degree 
as he closed his eyes when a brilliant light was thrown into 
them. Smell was absent, but as he rejected meat flavored 
with quinine or colocynth, even when hungry, taste must 
have existed. The ability to eat and drink, which was absent 
at first, returned, and his actions were then those of a normal 
dog with the exception that his food and drink had to be 
presented to him. He was deeply demented and showed 
absence of all those actions which we refer to sense, memory, 
reflection and intelligence in these animals. The decere- 
brated dog is not to be considered an insensible reflex 
mechanism, he is as intelligent as the human infant. The 
author believes from the observed facts, that the position of 
the partisans of cerebral localization, " that a minute portion 
of the cerebrum, a so-called centre, should control functions 
which the decerebrated dog, which has not these centres, 
shows, is utterly untenable". A dog without the so-called 
anterior leg centre should not howl or snap at the experi- 
menter's hand when the leg is hurt, but he does it. A dog 
which has lost the sensory centre for the eye should not 
flinch when the eye is touched by a needle, etc. These 
statements are false; for a dog which has no sensory centres 
whatever does all the things he should not be able to do. A 
dog minus the auditory centres should be deaf and mute, but 
he is anything but mute. Others claim that a dog without 
motor centres should be paralyzed. This myth must go 
with the rest. The dog minus a cerebrum is not paralyzed; 
he is only too lively in his paroxysms of rage. The pro- 
found symptoms observed after the removal of the cerebral 
hemispheres are not, in Goltz's opinion, altogether omission- 
symptoms due to the removal of definite centres, but are in 
part due to an inhibitory impulse started in centres lower 
down by the irritation of the cerebral injury. The fact that 
dysphagia with entrance of food into the larynx occurred 
for a long time, shows an inhibition of the function of the 



138 neurological. [December, 

medulla. For the greatly varying duration of the inhibitory 
impulses Goltz can find no plausible explanation. As the 
most important loss due to removal of the cerebrum he 
considers that of the processes which we can group as mind 
in these animals (memory, reflection and intelligence). 

G. J. KAUMHEIMER. 

The Optic Centre and Eye Movements. — Munk (Sitz.- 
Ber. d. K. Acad. d. Wiss.) reports the result of experiments 
made with the assistance of Obregia. Schsefer has demon- 
strated that electrical irritation of Munk's optic centre 
causes definite co-ordinated movements of the eyes. The 
movement is always from the irritated side and is com- 
bined with a movement downward, if the anterior, and 
upward if the posterior portion of the optic zone be irri- 
tated. Munk does not believe this to be due to an associative 
stimulation of the motor eye centres, as stronger currents 
produce only movements of the eyes, and circumcision of 
the centres, which severs the association-fibers, produces no 
effect on these movements. Section of the projection fibers 
abolishes these movements. From these facts, M. assumes 
that as a result of the stimulation of these segments of the 
optic centre, the animal has the sensation of vision and 
turns its eyes to the point in space which this picture 
occupies. As very much stronger currents are necessary to 
produce this effect after excision of the cortex, and as 
narcotics reduce its intensity to an extraordinary degree, it 
would seem to be proven that it is due to the stimulation of 
cortical elements. — (Deutsche Med. Wochensch.,~No. 34, 1892.) 

G. J. KAUMHEIMER. 

Cerebral Nerve Fibers and Organs of Movements. — 
Drs. P. Blocq and J. 0. ZanoffCGaz. desHop., Sept. 8, 1892) con- 
clude that the thoracic members to which pass the greatest 
number of cerebral fibers are, above all others, destined to 
intelligent movements which require special cerebral inter- 
vention. This functional adaptation has evidently led to 
development of ways of communication with the brain. 
Thus are also explicable reflex movements on which the 
brain exerts a moderating influence; particularly the ten- 
don reflexes, which, under normal conditions, are much less 
developed in the thoracic than the abdominal members. 
These last are most employed in automatic, unconscious 
acts requiring little cerebral intervention. Pathologically 



1892.] ANATOMY AND PHYSIOLOGY. 139 

speaking, the same is true. The upper extremity in cerebral 
lesions is more frequently and decidedly affected than the 
inferior, and return of mobility is less rapid and less com- 
plete. Psychic paralyses are more frequent in the superior 
members but more tenacious in the inferior. 

J. G. KIERNAN. 



Graphology and its Centres. — Varinord points out 
(Revue de V Hypnotism, July, 1892) that for writing, the 
graphic centre of the foot of the left second frontal convo- 
lution innervates and moves the muscles of the fore-arm and 
hand, and produces subconscious movements in the latter 
which produce handwriting characteristics. In so compli- 
cated an action, therefore, an external influence may lead 
to modifications, and there is reason to believe that the same 
action will produce the same reaction under every cir- 
cumstance, whence a particular type of handwriting will 
result for each of its influences. 

J. G. KIEBNAN. 



The Vaso-Motor Action of the Sympathetic. — Cavaz- 
zani (Rivista Sperimentale, XVIII, II, Aug., 1892) after dis- 
cussing the investigations of preceding authors, Gaertner 
and Wagner, Hurthle, Schulten, Ray, Sherrington, and 
others on the regulation of the cerebral blood supply, details 
his own experiments on rabbits and dogs in which he 
studied the blood pressure in the circle of Willis with a 
manometer and kymograph, stimulating the cervical sym- 
pathetic nerves mechanically and electrically, taking pre- 
cautions to avoid, as far as possible, any sources of error 
that might have existed in former investigations. Besides 
the pressure in the brain, the general blood tension of the 
body was also taken account of and recorded, and control- 
experiments by the method of artificial circulation were also 
made, the results of which were in entire accordance with 
those by the graphic method. His conclusions are 
formulated as follows : (1.) The system of the great 
sympathetic in the cervical region co-operates in the inner- 
vation of the cerebral vessels. (2.) It there assists with 
both vaso-constrictor and vaso-dilator fibers; the former 
directly excitable by electric stimuli, and the latter by the 
same and also by the stimulus of anaemia. (3. ) The vaso- 
motor action of the sympathetic, under ordinary conditions, 
is not produced on the cerebral vessels, or is very slight, 



140 neurological. [December, 

while it is energetic, even to producing vascular cramp, dur- 
ing mechanical and electrical excitation. (4.) The excita- 
tion of the vaso-dilator fibers is due to auaamia rather than 
to lowering of the pressure in the vascular ramifications. 

H. M. BA^XISTER. 



NEUROLOGICAL 



PATHOLOGY AND SYMPTOMATOLOGY. 

Cystic Tumor of Left Lateral Ventricle. — The 
patient was an ill-nourished, kyphotic female, 47 years old. 
She gave a history of cardiac trouble. About a month 
before admission she had an apoplectic seizure of short dura- 
tion which left some disturbance of speech and a weakness 
of the right arm, which gradually became worse. Syphilis 
could not be proven. On admission there was incomplete 
paralysis of the right arm and paresis of the right leg. Sen- 
sation and reflexes were normal. There was right hypo- 
glossal paralysis, slight aphasia and moderate dementia. 
Neither headache, vomiting, slow pulse, choked disc, nor 
paralysis of the ocular or facial muscles were preseut, 
although a distinct difference in the size of the pupils was 
seen. In a week a complete spastic paralysis of the right 
arm had developed ; in the leg it occurred later. At the 
same time there was hyperesthesia. Speech soon became 
unintelligible. The left side of the face became paralyzed, 
but showed clonic spasms, especially of the sphincter oculi. 
The limbs on the left side were also frequently involved in 
spasm, which increased in intensity shortly before death. 
At this time percussion of the head elicited an expression 
of pain on the left side of the face, the right remaining 
rigid. The intellectual faculties speedily became ex- 
tinguished until coma with paralysis of sphincters set in 14 
days after admission. In this condition she remained, with 
but slight lucid intervals until death, after a stay of 30 
days in hospital. Autopsy showed flattening of the gyri, 
especially on the left side. The left ventricle contained a 
cystic tumor covering the thalamus, being S cm. long and 6 
cm. broad. The cyst wall was smooth, translucent, of a 
pale red color, and covered with a fine network of vessels. 
The fluid was clear and of a pale yellowish-red color. The 
tumor, which was a typical spindle-celled sarcoma, had 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 141 

developed from the choroid plexus and had destroyed the 
posterior part of the caudate nucleus and the postero-lateral 
portions of the left thalamus. The author then discusses 
all the published cases of tumor of the thalamus and 
reaches the rather unsatisfactory conclusion that there are 
no focal symptoms which can be referred to lesions of this 
ganglion with reasonable certainty. — (Dr. Carl Hirsch, 
Berlin. Klin. Wochensch., Nos. 29-30, 1892.) 

G. J. KAUMHEIMER. 



Intra-Cranial Tumor Compressing Left Frontal Lobe. 
— Dr. Morrison reports the following case, which first came 
under his observation in 1886, the only symptom then being 
pain in head which he at that time attributed to localized 
syphilitic meningitis. In 1888 had an epileptiform convul- 
sion and pain in head gradually increased. In 1889 gave up 
work, speech became slower, eyesight began to fail, and, on 
stooping, pain increased in frontal region (during last nine 
months pain has not been so severe), memory for past events 
retained, that for recent events defective. Dec. 26, 1891, 
patient passed into comatose condition and died. Autopsy 
showed a tumor in left frontal region occupying greater 
part of left anterior fosse. The base of the growth measured 
2| in. vertically by 3J in. transversely; extended backwards 
into frontal lobe 2f in. Microscope showed spindle-celled 
sarcoma. The special features of this case are : evidence of 
slowly developing lesion accompanied by pain in head, not 
localized, single epileptiform convulsion, neuro-retinitis, loss 
of memory, slowness of mental process and speech, slight 
amnesic aphasia, absence of motor disturbance, and absence 
of signs of involvement of special senses other than sight. 
(Medical News, Oct. 29.) 

B. M. CAPLES. 

Thyroid Tumor Compressing the Pneumogastric. — Dr; 
Chibert reports (Mercredi Med., Nov. 2, 1892) the case of a 
56-year-old woman who entered an hospital for rheumatic 
pains. While there, as these improved, she submitted to an 
hysteropexy for uterine prolapse. She was transferred, sur- 
gically cured, to the medical wards for new rheumatic pains: 
Here she complained of suffocating sensations and retro- 
sternal pains. A week later she died suddenly. On autopsy 
a tumor was found behind the sterno-clavicular articulations 
compressing the trachea ; deviating to the right. The right 



142 neurological. [December, 

pneumogastric was raised by this tumor and adhered to it. 
The fibers given from it to the cardiac plexus were also 
raised and stretched. The tumor was of the size of a man- 
darin orange and fibrocystic. It was pediculately attached 
to the thyroid gland. There were few definite symptoms. 

J. G. KIERNAN. 

Cerebral Paralysis is the title of a clinical lecture 
delivered by Dr. Brower at the Woman's Medical College, 
Chicago. Dr. Brower exhibited two cases of paralysis, 
both single men, fifty years of age, neither of whom gave 
a history of previous ill health or of alcoholism. Heart, 
lungs and visceral organs practically normal ; muscles not- 
atrophied but reflexes exaggerated on paralyzed side; in 
one case slight aphasia. The presence of reflexes 
and absence of atrophy excludes myelitis or peripheral 
disease as cause of paralysis, so it must be cerebral. The 
four causes of cerebral paralysis are : congestion, embolism, 
thrombosis, and hemorrhage. Paralysis resulting from 
congestion is characterized by complete unconsciousness 
at the beginning of seizure, and recovery from the 
paralysis is usually speedy and complete. Neither of 
these men lost consciousness and the recovery up to date 
has been trifling. The second cause, embolism, has a history 
similar to the two cases with the exception that cerebral 
embolism is almost invariably consequent upon endocarditis, 
and this usually follows rheumatism. No heart 
disease nor rheumatic history in either case. Throm- 
bosis, the third cause, is the result of chronic degener- 
ation of the blood-vessels requiring months and years for 
its completion, and during this period are many evidences 
of disturbed cerebral function. No such history in 
either case. Eliminating the first three causes leaves 
cerebral hemorrhage to be considered. This is the most 
frequent cause of cerebral paralysis and is consequent upon 
some degeneration of the blood-vessels, usually a peri- 
arteritis. This condition usually belongs to old age, but 
there are other causes of degeneration of blood-vessels to be 
found in patients of fifty that may be the foundation of the 
hemorrhage, such as chronic Bright's disease, chronic alco- 
holism, and syphilis. History of the cases throws out the 
first two causes. The men acknowledge no syphilitic 
history and there is absence of its ordinary symp- 
toms, nevertheless, for want of other causative 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 143 

factors, the degeneration is a probable outgrowth 
of syphilis resulting in cerebral hemorrhage. The 
next important point to be considered in these cases is their 
probability of recovery. In cerebral paralysis one is 
justified in making a favorable prognosis unless secondary 
contractures appear. Six or eight weeks is as early as we 
have reason to expect occurrence of secondary contractures, 
and usually three or four months elapse before they are well 
developed. In the cases exhibited the onset was that 
form called simple, but the more usual is apoplectic, 
where the patient loses consciousness, usually falls and has 
complete muscular relaxation. The third form of onset is 
epileptiform: the patient loses consciousness and has an 
epileptiform seizure. In the apoplectic form nothing is to be 
done except to place patient in a recumbent position and, if 
the lesion can be located, a continuous, moderate pressure 
over the carotid artery on that side will tend to limit the 
hemorrhage. A drop of croton oil placed upon the tongue 
will usually result in a speedy action of the bowels. When 
consciousness returns, further hemorrhage may be relieved 
by bromides and ergot. Ten to 15 grains of bromide of 
soda or potassium and 15 to 20 minims of fluid extract of 
ergot may be administered once in three or four hours for 
this purpose, and as the danger of recurrence of hemorrhage 
decreases the doses of ergot and bromides should be 
diminished. After three or four days the ergot may be 
withdrawn and iodides substituted for the purpose of 
absorption. A week or two after seizure the patient will 
probably have some added cerebral disturbance, such as 
headache, fever and delirium. These symptoms call for a 
renewal of the ergot and bromides and careful attention 
should be paid to the bowels at the same time. When this 
secondary disturbance has disappeared massage and 
Swedish movement may be used in connection with electric- 
ity. Tonics should be used internally and careful atten- 
tion must be paid to elimination by skin, bowels and 
kidneys. If the paralyzed members do not improve under 
this treatment it is wise to inject strychnia into the muscular 
tissues : a daily dose of ^60 of a grain in the arm one day 
and the leg the next, during the progress of the treatment. 
As the only way by which control of the brain over these 
paralyzed members can be re-established is by opening up 
new paths for the conduction of the motor impulses, the 
patient should be urged to exert all the will-power he 



144 



XEUE< 



:cal. 



[Decern": ei 



possesses in enorts a: muscm; 
medical aid is mactiiahv use' 
Reiki. Dec. 1S92. 



lit. as otherwise 

hbhuyo C in ice. 1 . 



Bulbar Paralysis. — Hoppe. 
cribes four cases. two of which 
heimer. one by Wilks and one 
clinical history ='„:~s nionv 
Duehenne's bulbar paralysis. 1 
motor area, usually in one supp 
disease progresses slowly and 1 
but there is no atrophy and no 1 
Temporary improvement is : 
change is >ften seen in the conrse of a single day. In all 
of the cases the disease progressed without eomclic:. tonis 
d in. death. The autopsies with microscopic exam- 
ination were 11 e native. The author believes that there are 
minute manges in the cortex which cannot be discovered 
by our present means of observation, (Bielschowsky Neuro- 
logixhes Centralblatt. No. 15. 1892.) 

J05. KAH>". 



in Berliner Klin. Wock., des- 

were eb served Vy Oppen- 
by Eisenlohr, in which the 
points of similarity with 
he paralysis begins in some 
led ova cranial nerve. The 
nds in complete paralysis, 
hange in electrical reaction. 
:e:.ueut and 



cousk 



Laryngeal Paralyses in Locomotor Ataxia. — 1 
paraivses of the larvnx are 0: ^reat interest, not onlv to the 
Laryng >logist, but also to the neurologist. Krause has found 
the centre for phonation in the ::rtex. a discovery verified 

by Horsley and Semon. and has also determined the p.uhs 
of the ph::ia:i:n impulse, as well as centres and paths for 
the respiratory function. The rational explanation of clin- 

5 s a m pt n : the existence of 



T 



?. Semon 

•s in which one 

juration in t he 

is was observe.; 



ical phenomena requires tne 

independent centres for thes 
Rosenoach have independent 

position for phonation; and 

ease passed into the :adaveri 
in the course oi lesions 01 I 
vaults and recurrent nerves. 

of the motor nerves c 
[Semon] in which fchei 

the aodnctors and .ater tne auanctors :•: tne vooa. :oras are 
paralyzed. Horsley and Semon have located a respiratory 
centre in the medulla. Krause and others denv a raralvsis 



is 01 1 Lie 

3uS stated tne 



e Centres as we 
hsenbach has sts 

vet oeen noted, that in all lesions 
the larynx 1 and their centres, 

; net ads: late loss of conduct: 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 145 

and attribute the position to a spasm of the adductors. 
Grabower reports the case of a tabetic male whose left vocal 
cord remained very near the cadaveric position during quiet 
respiration. In deep inspiration it moved tremulously out- 
ward and approximated its fellow during phonation, pro- 
ducing loud, clear tones. There was consequently an 
isolated paralysis of the left crico-arytenoideus posterior with 
no contracture of the adductors. There are about 40 clear 
cases of laryngeal paralysis in tabes on record, but an 
isolated paralysis of this nature is very rare indeed. There 
is no doubt that a secondary contracture of the adductors 
will take place, but there is also none that the present con- 
dition is due to a paralysis of the abductors and not to a 
spasm of the adductors Semon has seen such a case last 8 
years, and it is quite improbable that a spasm of the adduc- 
tors, either of peripheral or central origin, should last that 
length of time. (Deutsche Med. Wochensch., No. 27.) 

G. J. KAUMHEIMER. 



Disturbance of Speech and Voice in Paralysis Agi- 
TANS.-Dr. A. Rosenberg exhibited a patient before the Berlin 
Laryngological Society in whom the laryngeal muscles were 
implicated in the disease. The patient, 62 years old, had 
had the disease for 30 years. He was the first patient in 
whom the bending back of the head had been noticed and 
described by A. Hermann in 1888. Although speech was 
modified by the tremor of the head it presented certain 
peculiarities even if the tremor of the head was suppressed. 
It was choppy, with involuntary pauses often lasting several 
seconds between the syllables, especially of a long word, so 
that the pronunciation of the second word or syllable was 
impeded. It differed from the scanning speech of sclerosis 
in the fact that the pauses were of variable duration. This 
irregularity was due to the involvement of the lips, cheeks, 
tongue and throat by the paralysis. If the patient was 
excited the soft palate could be observed to contract from 3 
to 6 times in rapid succession followed by a variable interval 
of rest. The epiglottis was frequently drawn down to a 
position of deglutition. Laryngoscopic examination showed 
a like involvement of the vocal cords. The cords were seen 
to be involved in the tremor like the voluntary muscles. 
The phonation position could not be kept longer than 7 to 8 
seconds. At the same time the voice changed from a high 



146 neurological. [December, 

to a low pitch. The spasm only occasionally occurred dur- 
ing quiet respiration ; sensation in pharynx and larynx was 
normal. The author then reviews the various phenomena 
presented by the larynx in different nervous diseases and 
points out the differential diagnosis. — (Berl. Klin. Wochensch. 
No. 31, 1892.) 

G. J. KATTMHEJLMER. 



Oculomotor Paralysis. — Schlesinger, at the Vienna Me- 
dical Club, showed a case with complete paralysis of the 
oculomotor nerve of the left side. Numerous pigmented 
spots were seen on the forehead which were the result of 
herpes zoster. The paralysis occurred one week after the 
appearance of the herpes. Such cases must be extremely 
rare as only one similar case can be found in medical 
literature.— (Prag. Med. Wochensch., No. 42, 1892.) 

JOS. KAHN. 



Exophthalmic Goitre with Oculomotor Palsy. — 
Schlesinger, at the Vienna Medical Club, reported a case 
with exophthalmos, tachycardia and enlarged thyroid, a 
typical case of Basedow's disease. When the patient extends 
her fingers they present a fine tremor. When the eyes 
follow an object in an ascending plane the lids remain 
stationary, not so in a descending plane. The right 
superior rectus muscle is paralyzed. Paralysis of the 
muscles of the eye is not rare in exophthal- 
mic goitre, but usually the internal and external recti are 
affected, or there is complete ophthalmoplegia. Paralysis 
of the superior rectus has never before been observed. 
Recklinghausen has shown that in exophthalmic goitre a 
fatty degeneration of the muscles of the eye may appear. 
Other observers hold that the paralysis may be due to disease 
of the medulla or of the peripheral nerves. Hysteria and 
tabes, which are sometimes given as causes, can be absolutely 
excluded in the case under consideration. — {Prag. Med. 
Wochensch. No. 42, 1892.) 



JOS. KAHN. 



Peripheral Affections of the Optic Nerves in Hys- 
teria. — Prof. Th. Leber believes that many cases of 
visual trouble in hysteria are due to a transient retrobulbar 
optic neuritis. Continued examination with the ophthal- 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 147 

moscope will show, sooner or later, even if the amblyopia 
recedes in a few days, a pale papilla. This is not to be 
counted as due to any decided atropy of nerve fibers, but 
rather to changes in the neuroglia. This form of neuritis 
requires but slight treatment; small doses of salicylate of 
soda or potassium bromide, and later, hypodermics of 
strychnia, being all that is necessary. A number of illus- 
trative cases is given. (Deutsche Med. Wochensch., No. 33, 

lOoZ. ) G. J. KAUMHEIMER. 

Hysteria with Organic Disease. — Babinski has reported 
to Paris Hospital Medical Society (La Tribune Med., Nov. 17, 
1892) nine cases of organic diseases in which hysteria 
existed. One was a case of ordinary spasmodic hemi- 
plegia; one case of diffuse meningo-encephalitis; one 
case of facial paralysis; one case of peripheral neuritis; 
one case of neurasthenia ; one of cervical endometritis ; 
one of organic coxalgia; one ol scapulo-humeral periar- 
thritis. J. G. KIEKNAN. 

Hysteria in Children. — Dr. Paul Winge, in a paper 
read before the Norwegian Medical Society, reported four 
cases of hysteria in children. They all were supplementary 
to one other, for, taken all together, they presented all the 
symptoms of the disease. In the second case the paralytic 
and dystrophic symptoms were most prominent, while the 
others were less distinct. In the first and third cases the 
sensitive and sensorial symptoms, as well as the character- 
istic psychic symptoms and spasms, were more marked. 
The first was the most typical case. Here there was a dis- 
tinct hysteric " temperament " with deficient nourishment, 
spasmodic attacks of varying duration and character, hys- 
teric zones, mutism, deafness, and deficient vision in the left 
eye. The lower extremities were also paretic. No anaes- 
thesia. The second case also had spasmodic attacks, hys- 
teric zones and paresis while no hysteric " temperament " 
was perceptible. No sensorial symptoms or anaesthesia. 
The third case presented an hysteric " temperament " and 
deficient nutrition, attacks of spasms, complete anaesthesia, 
mutism and hallucinations of sight. To these may be 
added catalepsy and paralysis of the lower extremities. In 
the fourth the dystrophic and paralytic symptoms were 
most prominent of all the four. The field of vision was 
diminished. Her " temperament " was not especially hys- 



148 neurological. [December, 

teric. None of the patients presented anything of import- 
ance in deviations from the normal in either their corporeal 
or psychic development. The first was 11 years old, the 
second, 12J years, the third, 10 years, and the fourth, IB 
years of age. The first two were males, the other two 
females. As to the treatment, the first was given prolonged 
baths, chloral and electricity, the other three, besides 
removal from home, received general suggestions in the 
waking state, tonics, and the two girls, arsenic. The 
second also was given the iodide of potash as a cerebral 
tumor was feared to be present. The prognosis was good 
in those without hereditary involvement, but doubtful, or 
even unfavorable, in the first case, where a hereditary taint 
was possible. The Norwegian literature contains but little 
on this subject. Skjelderup contributed a monograph on 
the disease in children, in 1863, but describes no cases ; 
Faye, 1875, mentions it, but presents no cases. The Norsk 
Magazin for Lsegevidenskaben for 1891 contains three cases. 
One of these, described by M. Holmboe, from the Rots void 
Asylum, was that of a thirteen year old boy, the son of a 
fisherman, who was treated at the asylum from the 8th of 
April till the 9th of August, 1889, and improved. The 
other two cases were communicated by A. Selmer, of Bais- 
fjorden, Nordland. They concerned two little girls, the one 
thirteen years of age and the other twelve. Both were 
cured. These were reported in the March number of the 
Review of Insanity and Nervous Disease, No. 3, 1892, from the 
Norsk Magazin for Lsegevidenskaben, No. II, 1892. Dr. E. Bull 
reports two further cases in the same number of this same 
journal. They were a brother and sister of the same 
family, aged, respectively, 10 and 11 years. The sister was 
first attacked and the brother infected soon after. They 
were treated with some degree of success as long as they 
were separated from their friends, but on restoration to 
their family they relapsed. Finally they were sent to the 
country and disappeared from view. Dr. L. Schibbye, in a 
third article in the same journal, the same number, records 
a case of hysteria in a nine year old girl who suffered from 
ischuria at the same time, which he thought to be of hys- 
teric origin. The ischuria was especially obstinate, though 
it improved under the use of hyoscyamus and camphor 
together with suggestion in the waking state. She im- 
proved to relapse again on returning to her relatives. 

FRANK H. PRITCHARD 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 149 

Normal Hysteria. — The subjects of this class of experi- 
ments were ten in number, seven women and three men. 
The experiments were made as follows: the patients were 
weighed and their temperature noted every two days ; the 
urine was collected every ten hours. The duration of the 
investigation averaged eight days for each patient. The 
volume of urine, the quantity of fixed residuum, urea and 
phosphoric acid were noted. The results which the authors 
obtained led them to conclude that in normal hysteria (the 
form in which the manifestations consist in permanent stig- 
mata) the nutrition is effected in a normal manner. Patho- 
logical Hysteria. — Gilles de la Tourette and Cathelineau in a 
first series of experiments studied the modifications of nu- 
trition induced by convulsive attacks in hysteria. In regard 
to this they had been preceded by but a few other authors. 
Among these is Rummo who had, from his numerous anal- 
yses of urine obtained every two hours before and after the 
attacks, found that in convulsive hysteria the bodily ex- 
change of material is positively decreased. It is known that, 
according to the classic studies of Charcot, the typical 
hysterical convulsive attack is divided into four phases : (1) 
the epileptoid period ; (2) that of general movements ; (3) 
that of passional attitudes; and (4) that of delirium. 
If it is generally admitted that the urine is more abundant 
after the attack, very different opinions prevail in regard 
to its composition. The experiments were made on ten 
hysterical patients, 8 men and 2 women, in all, 92 analyses 
of urine during 38 attacks. The patients were under ob- 
servation from the beginning of the attack till 24 hours 
after. If it began, for instance, at 6 P. M., the urine was 
collected from that hour to the corresponding hour the fol- 
lowing day. It was collected in two vessels, one containing 
the first passed (primary urine) and the other receiving all 
the rest during the attack (secondary urine). None of the 
subjects showed symptoms that would affect the nutrition 
(anorexia, vomiting.) — Quantity of Urine. While normally 
the amount of urine passed at one time varies between 150 
and 200 grams, it was found that in these patients the pri- 
mary urine rose to as much as 700 grams (over 23 oz.) The 
primary urine in several cases was greater in quantity than 
the whole amount passed later, and it averaged one third of 
the whole ; the total quantity was not increased. The in- 
tensity and duration of the attack did not seem to exert 
any influence upon the amount. The primary urine was 



150 neurological. [December, 

limpid, the secondary, an orange yellow. Both were slightly 
acid and odorless. The density of the total urine averaged 
1016 ; that of the primary urine varied from 1004 to 1010 ; 
that of the secondary from 1025 to 1026. The fixed resid- 
uum, the most important matter of the analyses, was the 
same in all the subjects. In healthy individuals this varies 
between 40 and 52 grams in 1000 cubic centimeters of urine. 
In the ten patients it was constantly below the normal 
figures and varied between a minimum of 39 grams and a 
maximum of 47 grams and averaged between 35 and 38, 
while the normal average is 46.38. The conclusion, there- 
fore, is that a hysteric convulsive attack diminishes the fixed 
residue of the daily urine by about one third. As regards 
the principal elements of this residuum the following are 
the results of the analyses. Urea. In both primary and 
secondary urine the ratio of urea was below the normal and 
tbe primary urine contained only one tenth as much, on the 
average, as the secondary urine. In the women the normal 
excretion of urea varied between 10 and 24 grains in 24 
hours, while it ranged between 10 and 17 on the day of the 
attack. In the men it was also proportionately reduced. 
Phosphates. In the healthy person, as well as in the hysterical 
one, in the normal condition the total amount of phosphoric 
acid varies during the 24 hours between 2 and 2.57 gr. In 
the ten hysterical subjects at the time of the attack, the 
total quantity of this acid ranged between 0.70 and 0.71 gr. 
with an average of 1.24, while the normal average of these 
ten was 2.19. The phosphoric acid normally excreted in the 
urine decomposes into earthy phosphates (lime and mag- 
nesia) and alkaline phosphates (soda and potassia), the latter 
in excess to the former in the ratio of 100 to between 25 and 
44. In the ten subjects, however, the ratio, normally about 
1 to 3, became at the time of the attack 1 to 1. The tendency 
of the attack is, therefore, to equalize the two. These state- 
ments apply to the totality of the urine, but are applicable 
also to the primary and secondary urines, with this peculi- 
arity, however, that the primary is very poor in phosphoric 
acid as compared with the secondary, according to the two 
French authors ; these results, to which they give the name 
of inversion of the formula of the phosphates, are pathognomonic 
of the hysteric attack. The same phenomena were observed 
by Chautemesse in a case of hysterical pseudo-meningitis. 
Chlorides. The excretion of chlorides follows the same rule ; 
during the attack they are generally decreased. In only 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 151 

three instances did there seem to be an increase. The mean 
varied between 8 and 12 grains. Some authors have 
noticed the presence of sugar in hysterical urine (Gibbs, 
Goolden), others have found albumen, but Gilles de la 
Tourette and Cathelineau found neither in their analyses. 
The two authors conclude from the above stated facts : "That 
the hysterical convulsive attack is characterized by a general 
retardation of nutrition. The fixed residue, the urea and 
phosphates, are diminished about one third as compared 
with the normal state. The proportions of earthy to alka- 
line phosphates, normally 1:3, tends to become 2:3. In- 
crease of the fixed residue, when verified, is due to aug- 
mented excretion of chlorides." The primary urine is 
greater in volume than the secondary, but its solid constit- 
uents are comparatively small. The length and intensity 
of the attack accent the modifications of nutrition. Even 
an attack of a quarter of an hour causes changes that are 
shown by chemical analysis, and these modifications are 
met with after the attack for a period apparently not ex- 
ceeding 24 hours. Clinical observation shows that the class- 
ical hysterical attack of four periods is rarely met with. One 
period may predominate at the expense of the others and 
extraneous influences may modify it. The grand hysterical 
attack, therefore, has several varieties. Gilles de la Tourette 
and Cathelineau have studied the nutrition in two varieties. 
In one, the symptoms were those of partial epilepsy, in the 
others the attack was limited to the first period. The result 
of the examination of the urine in these two was nevertheless 
exactly the same as that in the classic type. The same 
result was met with in two cases of rhythmic chorea, one of 
hysterical cough, and one of hysterical yawning: hence 
they conclude that all these forms of hysterical manifesta- 
tions are chemically the same as the convulsive type. This 
confirms what Charcot had already established on clinical 
grounds. The state of the nutrition in the prolonged form 
of attack, or mat hysterique, characterized by a more or less 
continued succession of attacks lasting days or weeks, or 
even months, was also investigated by the French observers. 
In this form the type of any one of the four periods may 
predominate and give its name to the attack. In some 
instances the lethargic or somnolent period is continuous, 
and we have in such what may be called hysterical lethargy, 
or somnolence, which may be interrupted or alternated by 
one of the other phases, more particularly by that of the 



152 neurological. [December, 

passional attitudes. Gilles de la Tourette and Cathelineau 
carried on their researches in one case each of the epileptoid 
and passional types, and six cases of the lethargic type, one 
which extended over fifteen days. In these cases the urine 
was collected with the catheter. From all these they con- 
clude that the condition of mat hysterique, whatever form it 
assumes, is only a prolonged attack of hysteria, presenting 
the same phenomena, chemical and physical, of the urinary 
secretion. Noticing the curve of the urinary secretion it is 
seen that it is lowered in the beginning of the lethargic 
attack and rises at its close. As Charcot has observed, this 
has a valuable clinical signification since it is contrary to 
that in inanition, where the descent is progressive. On the 
day the patient emerges from the lethargic state, or it may 
be 48 hours before, there is a rapid ascent of the curve 
corresponding to a quantitative and qualitative increase, 
although there has been no aliment taken, either solid 
or liquid. This phenomena is so constant that it enables 
one to predict the duration of the attack and the early 
return to the normal condition. Gilles de la Tourette 
and Cathelineau made what seemed to be an important 
clinical deduction, their formula of the inversion of the 
phosphates appeared to them to be a valuable aid in the 
diagnosis of hysteria and epilepsy, which is sometimes so 
difficult. If, on examination of the urine, it is found that 
the solid matters are all diminished and the proportions 
of the earthy and alkaline phosphates approach equality, 
the case is hysterical, since, as Mairet and Rummo have 
observed, the excretion of these substances is increased in 
the true epileptic attacks. Fere and Voisin, however, have 
recently contested these conclusions and the matter is still 
subjudice. Among the more singular abnormal phenomena 
of hysteria must be included the increased bodily temper- 
ature sometimes observed, which has been described under 
the name of hysterical fever. Briquet (1859) reported be had 
found in 20 cases of hysteria a febrile condition lasting 
several weeks associated with intense headache, lively 
delirium and hysterical convulsions. Briaud (1883) dis- 
tinguished three forms of hysterical fever, a slow form, 
already described by Briquet, a brief form of typhoid type 
that marked the beginning of hysteria, and an intermittent 
form of the tertian type. Chautemesse, Baisard, Mac6 and 
others have described a pseudo-meningitic hysterical fever, 
distinguished by its rapid progress and quick re-establish- 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 153 

merit of health. Rosenthal states in regard to hysteric 
fever, in his treatise on nervous diseases, that it ordinarily 
occurs as a sequence of emotional conditions and is accom- 
panied with a decrease or increase of the temperature 
of 1.2 to 1.4 C. of the skin, face, neck and breast, while 
the axillary temperature oscillates between 37.4 and 37.6 
(=99.32 and 99.68 F.). One of the more noteworthy 
memoirs on this subject is that of Sarbo (Arch. f. Psych., 
1891) which, besides many references to the literature, con- 
tains a number of interesting observations. Sarbo distin- 
guishes two groups : in the first there is no real rise of tem- 
perature but other symptoms observed in fever are present 
(frequent pulse and respiration, tremor, sense of heat, &c), 
so that the general appearance is similar to a real febrile dis- 
order (hysterical pseudo-fever). The second group includes 
cases with actual rise of temperature (hysterical fever) and 
this he sub-divides into continuous and paroxysmal fever. 
Each of these two forms has, according to the temperature, 
a light and a severe variety. The following are this 
author's conclusions : A continuous fever may present 
itself in the course of hysteria without depending upon any 
organic affection. It appears under two forms, a light form 
with temperature not over 38.50. and a severe one with 
temperature from 38.5 upward. The duration may be days 
or months. This fever may be accompanied with symp- 
toms like those of other disorders (typhus, meningitis, 
phthisis, peritonitis). Sometimes, without any apparent 
cause, in the course of hysteria there appears a sudden febrile 
attack (paroxysmal fever) with greater or less rise of temp- 
erature. The febrile attacks may be associated with, or 
be independent of, convulsive attacks. The hysterical 
pseudo-fever, as well as continuous fever, may also be asso- 
ciated with paroxysmal fever. In 1878, the reviewer, Sepilli, 
published in connection with Dr. Maragliano a case of fever 
without known cause which must be referred to hysteria, 
and others are referred to that have been observed by 
Manzieri, Bordoni, Sciammanna, Hale White, Vigioli, 
Mierzyewsky, Esteres and Sacchi. The case of Vigioli is of 
special interest. A woman, 30 years of age, was taken with 
fever in January, 1891. During the first week the morning 
temperature ranged from 37 to 37.5, the evening tempera- 
ture from 48 to 38.5. The second week there were pro- 
gressively ascending oscillations up to 41°, and the third 
week, with the still elevated temperature there was a first 



154 neurological. [December, 

attack of lethargy with usual accompanying symptoms. 
After the attack, which lasted nine hours, the temperature 
rose to 43.5 (=110.3F.). These attacks of lethargy were re- 
peated at varying intervals with, subsequent high tempera- 
ture up to as high as 45 (=113. F.). It is noteworthy that 
sometimes a few hours later there was a rapid fall of tem- 
perature to 37., 36., 35., and even to 34.5 (=94.F.). Toward 
the end of the fourth week complete anuria appeared to- 
gether with incontrollable vomiting, which lasted seven 
days. The circulation and respiration were not influenced 
by the high temperature, and during the whole three 
months the patient preserved her strength and did not 
waste away. All the symptoms at last disappeared suddenly. 
In Mierzejewsky's case the temperature rose as high as 43 
and fell as low as 29.3 C. (=84.75 F.). Sometimes the 
range was 11° in the twenty-four hours and it reversed 
the usual order, being highest in the morning. At the 
same time the daily amount of urine diminished to 300 
cubic centimetres. In spite of the high fever there was no 
unusual perspiration or desire to drink. These clinical facts 
show that hypothermia may be a manifestation of hysteria. 
Rummo considers the rise of fever 1° to 3° observed in 
epilepsy as well as in hysteria, independently of the convul- 
sive attack, to be a true thermic equivalent of the attack. 
Chemical examination of the urine affords an important 
criterion to establish the diagnosis of hysteric fever. In 
Vizioli's case, the urine, analyzed by Prof. Primavera, showed 
a lack of all the principal solids and particularly of urea. 
Similar results were obtained by Scrammanna and Mierze- 
jewsky, and it therefore appears that this urine reverses the 
conditions of ordinary febrile urine. As regards patho- 
genesis, the most recent views attribute hysterical high 
temperature to functional changes in the cerebral thermic 
centres. This is the view of Sarbo, and it also explains the 
various so-called "nervous" and "functional" fevers. Hys- 
terical fever occurs very often without any known cause. 
Sometimes it is provoked by menstruation, traumatism, or 
psychic impressions, or it may precede or follow a convul- 
sive attack. Charcot has claimed that the temperature is of 
value in distinguishing status epilepticus from hystero- 
epilepsy, since in the former the temperature 
rises rapidly to a high grade while in the latter it does not 
exceed the normal figure. This rule, however, is not abso- 
lute. Wunderlich has reported a case of hystero-epilepsy 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 155 

with epileptiform attacks during eight weeks, who then, 
fallen into collapse, died with a temperature that had risen 
within a short time as high as 43 C. Rummo also saw a 
temperature before death of 41. 1C. in a patient suffering 
from genuine hystero-epileptic convulsions. According to 
Sarbo the increase of temperature after a series of convul- 
sions must not be considered as a diagnostic of epilepsy, as 
it may occur in hystero-epilepsy to which is associated the con- 
dition of hysterical fever. All the above facts taken together, 
says Seppilli, show clearly that we may find in hysteria a 
profound disturbance of nutrition, manifesting itself by a 
retardation of the processes of assimilation and disassim- 
ilation, together with modifications of thermogenesis. The 
anorexia and anuria without uraamic disorders, and the dim- 
inution of the solid matters in the urine during every form of 
hysteric attack, are phenomena that admit of no interpre- 
tation if we do not assume a deficiency of activity of tissue 
change in the system. This admitted, and holding that 
the regulations of tissue change, as has been clearly shown 
by Prof. Luciani in his studies on digestion, is a funda- 
mental function of the nervous system, does it not follow 
that all these hysterical phenomena should be referred to a 
functional disturbance of that system ? 

H. M. BANNISTER. 

The Nutrition in Hysteria. The following are some 
of the principal points in a critical review of this subject 
and its literature by Dr. Seppilli in the Revista Sperimentale 
di Freniatrica XVIII, II, 1892. Taking up, first, the subject 
of hysterical anorexia, he refers to Gull's apepsia hysterica 
(1873) contemporaneous with Lasegne's description, and a 
little earlier than Huchard's "mental anorexia". In some 
hysterical cases the cause of the anorexia is a sense of dis- 
comfort, of weight or pain in the epigastrium associated some- 
times with vertigo. The patient considers eating to be the 
cause and reduces his diet to a minimum. The idea becomes 
a fixed delusion and abstinence is the result. In other 
cases motives of coquetry are the cause, the patient wants 
to appear interesting, has objections to gaining flesh. In 
others the refusal of food is due to the lack of the feeling of 
hunger, and this is the most frequent cause of hysterical 
anorexia. In two cases described by Sollier it was due to a 
sensory illusion, macropsia, the patients saw the volume of 
the food so magnified that they had not the courage to try 



156 neurological. [December, 

to eat it. In the beginning general nutrition does not seem 
to suffer, there is an exaggerated activity and lack of dis- 
comfort, but after a longer or shorter period the symptoms 
of inanition appear. Emaciation progresses, the patients 
are reduced to living skeletons and confined to their beds, 
bodily temperature is reduced, the extremities become 
cyanotic and cold, thirst increases, the pulse becomes more 
frequent, the skin dry, and unless treated properly and in 
time death intervenes. As to the treatment it is noteworthy 
that isolation and removal of the patient from their families 
and surroundings often works marvellously well. Bernheim 
obtained in one case a cure by daily practice of hypnotic 
suggestion. A not infrequent cause of hysterical anorexia 
is vomiting. Charcot first called attention to the relations 
between hysterical vomiting and anorexia and anuria, and 
having found in one case that the vomited matters contained 
urea, he attributed the vomiting to the suppression of the 
renal secretion. Fernet came to the same conclusion after 
having found urea not merely in the matters vomited but also 
in certain other secretions, such as the saliva. (Seppilli here 
quotes in detail two cases reported by Gilles de la Tourette and 
Oathelineau apropos to this point.) The doctrine of Charcot 
of the uraemic origin of the vomiting in hysteria from sup- 
pression of the renal functions is not generally accepted for 
various reasons. First of all, Hepp of Strassburg, Bouchard 
and Empereur have shown that the vomited matters may 
contain urea independently of uraemia and hysteria. More- 
over, cases of hysterical anuria occur in which there is no 
vomiting. Cases of this kind have been described by Ros- 
soni and Hoist and are of interest as indicating that the 
theory of Charcot is not to be accepted too implicitly, and that 
in certain hysterical conditions there exists a profound dis- 
turbance of the organic material exchanges in the system ; 
a slowness of assimilation and disassimilation that prevents 
the excessive accumulation of products of consumption in 
the blood. This explains how anuria can be tolerated so 
long without imperiling life. That the vomiting of hysteria 
is not always of ursemic origin is also proven by cases in 
which the vomited matters show no traces of urea. The 
resistance to energetic medication shown by some hysterical 
cases is also probably to be referred to the slowness of assim- 
ilation. In one of Rossoni's patients, strong doses of pilo- 
carpine, ipicac, and strychnia failed to produce their usual 
symptoms. Dinian asserts that he has observed in Charcot's 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 157 

clinic a patient who took with impunity by inspiration two 
or three litres of ether. Some also show an unusual toler- 
ance of large doses of morphine hypodermically. The fact, 
that in some cases of hysteria there may be long abstinence 
from, and vomiting of, food, without any corresponding dis- 
turbance of nutrition, suggests a comparison between these 
and the phenomena of hibernation in animals. Following 
the suggestion of Charcot, Empereur instituted in 1876 a 
series of investigations on the condition of the blood, the 
assimilation, excretion, etc., but the results were not definite 
enough to remove the subject from the stage of hypothesis. 
More recently Gilles de la Tourette and Cathelineau have 
carried on in Charcot's clinic a more extensive and 
important series of researches (Progr&s. Mtd., 1888-'89-'90). 
These authors divide their work into two parts compre- 
hending subjects of normal and pathological hysteria. 

H. M. BANNISTER. 



Epilepsy. — This excellent article discusses some unusual 
features of the disease and some symptoms that are often 
unrecognized. In speaking of petit mal, the author says : 
"Petit mal may occur as a visual projection, the most 
common form being the ' seeing of faces.' I recall an in- 
stance of a middle-aged woman who complained of the 
appearance at intervals of faces causing her much annoy- 
ance. This phenomenon was accompanied by a slightly 
dazed feeling on the part of the patient." The author 
further says; "A great many of those cases spoken of as 
* fainting spells ' are unquestionably instances of petit mal. 
A man came to me recently who for many years suffered 
from simple ' faints '; very lately he had experienced two 
severe attacks of grand mal. There has recently come 
under my notice a woman who during the first seven years 
of her life had convulsive seizures, so-called 'worm fits.' On 
reaching puberty and up to the age of 33 she suffered from 
'fainting spells' prior to and during the menstrual period, 
sometimes having several such ' spells ' a day. At the age 
of 33 she developed grand mal and the status epilepticus. 
In connection with this case I desire especially to emphasize 
the dictum of Seguin that after the third year eclamptic 
attacks are very probably epileptic in character, and are 
quite certainly so if we can exclude syphilis and renal 
disease. Seguin says, also, that epilepsy may be differentiated 



158 neurological. [December, 

from ordinary syncope by the presence in the former 
of dilated and fixed pupils and wide open, staring eyes. 
A few weeks ago I saw in consultation a lady who com- 
plained of peculiar rythmical movements commencing in 
the right leg and involving in turn the arm and the head ; 
over these movements she had no voluntary control. The 
attack usually lasted but a few moments ; there was a defect 
of, but no loss of consciousness. She acknowledged that she 
was somewhat dazed when the seizures were more than 
usually severe. I have under my care at the present time 
a young man who is greatly annoyed by a strange, in- 
describable sensation which flashes over him whenever he 
becomes irritated or greatly excited. He has suffered from 
this for years, and in the absence of other symptoms I 
should hesitate to class it as epileptic in nature, yet I regard 
it with grave suspicion. 

Sensation in Epilepsy. — Dr. Fere states (Mercredi Med. 
Nov. 16, 1892) that local anaesthesia is so frequent among 
epileptics and degenerates that this symptom is of very 
problematical use in diagnosis between these states and 
hysteria. 

J. G. K1ERNAN. 



CONVULSANT LEUCOMAINE IN URINE OF EPILEPTICS. — Dr. 

A. B. Griffiths recently reported to the Paris Academy of 
Sciences that he had {Mercredi Med., Aug. 3, 1892) extracted 
from the urine of epileptics a leucomaine which produces 
in animals tremor, involuntary bladder and bowel dis- 
charge, pupillary dilatation and convulsion, followed by 
death. j. g. kiernan. 

A Case op Chorea-Nephritis. — An etiological connection 
between chorea and nephritis not due to endocarditis has 
not been heretofore reported. A boy, aged 14J years, 
developed chorea. Owing to idiosyncrasy arsenic was 
abandoned. A tonic and dietetic regimen without alcohol 
and with exercise in the open air was ordered. A week 
later his face was swollen; this was found to be due to a 
nephritis. The urine contained I per cent, albumen, with 
pale and hyaline casts and epithelial cells. Under appro- 
priate treatment the nephritis soon disappeared and with 
it, step by step, the chorea. The author is inclined to 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 159 

attribute the chorea to ureemic intoxication, although the 
urine had been normal 9 months before. (Prof. Thomas, 
Deutsche Med. Wocliensch., No. 28.) 

G. J. KAUMHEIMER. 



Huntington's Chorea. — Grippin reports a case of hered- 
itary chorea with autopsy, from which he draws the follow- 
ing conclusions: (1). Huntington's chorea is a disease of 
the central nervous system. Pathological examination 
shows organic lesions of the brain which closely resemble 
Hayem's non-purulent encephalitis. (2). The disease is 
always hereditary. Usually the children inherit the same 
disease but it may happen that, as a result of the hereditary 
tendency, neuroses and psychoses are transmitted. (3). The 
disease usually begins in the third decade of life, less often 
in the fourth or fifth, and very rarely either earlier or later. 
Insanity may appear as a complication. (4). The prognosis 
is always grave. (Archiv fur Psychiatrie, Vol. 14, No. 1.) 



JOS. KAHN. 



Hereditary Chorea. — Schlesinger reports a series of 
observations of hereditary chorea. The first case is that of 
a woman, thirty-eight years of age, in whom the disease 
began three years previously, grew steadily worse and ran 
into paretic dementia. Her father died of hereditary 
chorea. The second case is that of a man, fifty years of 
age, who has been sick for two years. During the past year 
his memory has grown weak and his speech has become 
defective. Five similar cases have been observed in his 
family. A child of the patient is an epileptic. In the 
third series of observations a whole family was affected. 
Three children developed chorea between the ages of twelve 
and fourteen. An uncle and a great-grandfather died of 
the same disease. In addition there were two severe cases 
of hysteria, one of melancholia, and one of paretic dementia 
in the family. As a result of his observations the author 
draws the following conclusions: (1). Hereditary chorea 
usually begins in adult life, although in a few exceptional 
cases it may appear in childhood. (2). As a rule, the dis- 
ease is transmitted from generation to generation, although, 
exceptionally, one generation may be entirely skipped. (3). 
It is possible that severe hysteria may occasionally take the 



160 neurological. [December, 

place of chorea in one generation. (4). The disease is pro- 
gressive and is not favorably affected by arsenical treatment. 
(Neurologisches Centralblatt, No. 19, 1892.) 

JOS. KAHN. 



Acromegaly and Bitemporal Hemianopsia. — Dr. Boltz 
reports a new case of acromegaly in a man of 41, which pre- 
sents the unique complication of a bitemporal hemianopsia. 
The defect was strictly bounded by the vertical meridian. 
Schulz has reported a case with left sided hemianopsia, Strum- 
pell another without stating whether the defect was in one 
or both eyes, and Litthauer, a case with concentric contrac- 
tion of the visual field. To explain this phenomenon we 
must assume a destructive lesion of the inner fibers crossing 
at the chiasm. This has been found to be due to fractures of 
the base, to aneurism of an aberrant artery running under 
the chiasm, to gumma and to sarcoma of the brain. As an 
hypertrophy of the hypophysis cerebri has been noted in 4 
autopsies on cases of acromegaly, in one even as large as a 
hen's egg, it is possible that a similar tumor growing in a 
forward direction may cause this peculiar symptom in this 
case. (Dr. R Boltz, Deutsche Med. Wochemch., No. 27, 1892.) 



G. J. KAUMHE1MER. 



The Muscular Atrophy of Joint Disease has been 
proven by Hoffer to be of reflex neurotic origin. He in- 
jected nitrate of silver into the knees of dogs and then cut 
the posterior roots of the lumbar nerves on one side. On 
this side no atrophy occurred, on the other it did occur. 
(Deutche Med. Wochenschr., No. 33, 1892.) 



G. J. KAUMHEIMER. 



Unilateral descending Amyotrophic Degeneration.. — 
The patient was a strong girl of 17, who was absolutely 
healthy with the exception of the condition noted. The 
right arm and leg were atrophied, livid and partly 
paralyzed. The shoulder and elbow were actively and 
passively movable, but weaker than the left. The fingers 
were flexed into the palm and drawn toward the ulnar side, 
the phalangeal articulations being extended. A constant 
tremor was present. The thumb was not involved. Pas- 
sive extension was easy. The foot was raised somewhat 
from the ground and the last four toes, especially the fifth, 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 161 

strongly flexed toward the sole. On attempting to walk 
the flexion increased, so that the patient was compelled to 
walk with the foot in a position of equino- varus. Disorders 
of sensation or of reflexes were not present. The electric 
excitability was changed quantitatively only. The extensor 
muscles of the fingers and toes were atrophied to a greater 
extent than their antagonists, so that the malposition was 
due to the preponderance of the flexors. From a minute 
consideration of all diagnostic points, which is too long to 
be reproduced here, the author reaches the conclusion that 
the condition is due to a descending degeneration of the 
pyramidal tract which had involved the anterior gray horn. 
This differs from the ordinary amyotrophic sclerosis in its 
extent, being unilateral, and in the nature of the lesion. 
Sclerosis is not probable, and, as the trouble was first noticed 
in the fingers, he attributes the entire symptom-complex to 
a slowly growing tumor in the anterior part of the right 
half of the cervical enlargement of the cord, probably a 
glioma. {Prof. Adamkiewicz, Wien. Med. Blaett., Nos. 26-27, 
1892.) 

G. J. KAUMHEIMER. 

Paramyoclonus MuLTiPLEX.-Kahane, at the Vienna Med- 
ical Club, reported the case of a laborer, twenty-nine years 
of age, who had some time previously suffered from 
pyaemia. The present illness began with violent tremb- 
ling of the entire body. When admitted to the hospital he 
presented the symptoms of paramyoclonus multiplex, as 
described by Friederich. The movements were symmetri- 
cal and synchronous, affecting the lower extremities but 
not the face. Speech was normal. The patient could con- 
trol the movements by an act of the will. If an attempt 
was made to forcibly control them in one portion of the 
body they became worse in another. Under hypnotic treat- 
ment the symptoms disappeared only to recur after a short 
interval. This treatment seemed to depress the patient's 
mental condition. Kahane believes that the disease was 
due to hysteria. (Prag. Med. Wochensch., No. 42, 1892.) 

JOS. KAHN. 



A Peculiar Occupation Spasm. — Dr. Tranjen describes a 
case of spasm of the superior oblique and internal rectus 
muscles of the left eye, occurring- whenever the head was 



162 neurological. [December, 

turned to the right. The patient, who was an officer, claims 
to have contracted the trouble while a cadet. At that time 
he was, for two years, stationed at the extreme left of his 
company during drill, and was compelled to over-exert 
these muscles while " dressing the front." From a study of 
the position of the head during drill Tranjen believes this 
to be the true explanation. It is analogous to writer's, 
pianist's or telegrapher's cramp. (Berlin. Klin. Wochensch., 
No. 33, 1892.) 

G. J. KAUMHEIMER. 

Angio-Neurotic (Edema. — Dr. Legendre reports (La Trib- 
une Med., Nov. 17, 1892) the case of a thirty-three-year-old 
man in whom there had occurred, during fifteen years, 
partial oedemas, localized usually in the extremities (hands, 
fore-arms, feet and malleolar regions) but sometimes in the 
scrotum. These oedemas, as a rule, appeared suddenly and 
symmetrically. They usually lasted about three or four 
days and disappeared quickly. By their firm consistency, 
slightly cyanotic state and skin heat, and their rapid cyclical 
evolution, these oedemas were clearly of neurotic origin. 
The patient had the facies and emotionalism of a neuro- 
path and suffered at times from the globus hystericus. In 
the present case the problem was complicated by 
the existence of interstitial nephritis, slightly ad- 
vanced, (slight albuminuria, intermittent pollakiuria; 
co-existing often with the disappearance of the oedema, 
crysesthesia, feeble bruit de galop). The source of the 
nephritis seemed to be a typhoid fever from which the 
patient suffered three years prior to the appearance of 'the 
oedema. The periodical and cyclical character, the seat and 
the duration of the oedemas, their appearance, and the fact that 
they did not affect the face or eye region, showed that they 
were not of albuminuric origin. There were no evidences 
of a rheumatic origin. The hereditary antecedents were 
neuropathic, not arthritic. 



J. G. KIERNAN. 



Angina Pectoris Nervosa in the Male. — Dr. A. Peyer 
has found numerous patients presenting the symptoms of a 
cardiac neurosis, as stabbing pains, palpitation and oppres- 
sion, to be suffering from sexual neurasthenia. On treating 
the genito-urinary organs the cardiac symptoms promptly 
disappeared. He gives the history of eleven cases. A care- 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 163 

ful inquiry into the previous history of the subject will be 
of great assistance in diagnosis. ( Wien. Med. Presse, No. 27, 
1892.) 



G. J. KAUMHEIMER. 



Propulsion and Retrogradation. — Dr. Lebrau (Presse 
Med. Beige., Aug. 28, 1892) has observed the case of a non- 
neuropathic, non-alcoholic, tobacco-using man who, at the 
age of seventy, experienced an involuntary tendency to 
run rapidly forward. This disappeared but two years later 
he had a similar tendency to run backward. This often 
caused him to fall. There were no other symptoms except 
*' tobacco heart." Lebrau believes that the action of tobacco 
upon the heart sufficed to produce mesencephalic circulatory 
disorders which were the cause of the symptoms present. 



J. G. KIEUNAN. 



Ischias Scoliotica. — The complication of sciatica with 
a deviation of the spinal column does not seem to have 
received much notice in this country. A number of Con- 
tinental authors have reported cases and it seems to be of 
relatively frequent occurrence there. In connection with 
the description of five new cases Dr. Higier (Deutsche Med. 
Wochensch., No. 27, 1892) reviews the various theories put 
forward to explain this phenomenon. It may present great 
diagnostic difficulties. Albert has recorded the case of an 
anaemic, cachectic man in which he gave a grave prognosis 
on account of supposed advanced caries of the vertebrae. 
To his surprise, a few years later he met his patient doing 
service as a soldier with no trace of his former deformity. 
The scoliosis may be heterologous with the concavity 
toward the sound side, which is the most frequent form, or 
homologous with the concavity toward the same side as the 
sciatica. Eemak has recorded a case where the patient was 
able to transfer the deformity from one side to the other at 
will with temporary relief to the pain. In addition to the 
lumbar deviation a compensatory dorso-cervical curve in 
the opposite direction develops. The deformity may set in 
with the pain or may occur at any time during its continu- 
ance, but usually disappears with it. Charcot, who seems 
to have seen only cases of crossed scoliosis, claims that this 
is the typical form and that from it we can always locate 
the painful side. Babinski suggests that the deviation is 



164 neurological. [December, 

the result of an effort, voluntary or involuntary, to relievo 
the affected member of the weight of the body and thereby 
prevent the pressure of the muscles on the nerve. This 
does explain the homolateral and alternating cases. Brissaud 
assumes for the homologous deformity an irritation of the 
motor fibers of the lumbar plexus, causing a spastic con- 
traction of the muscles. Nicoladoni, who was acquainted 
with the crossed form onlv, assumes that in the cases- 
accompanied by scoliosis the central portion^ of the nervo 
are affected. By bending the trunk toward the sound side 
the patient puts the inflamed half of the cauda equina in a 
position in which it is least exposed to pressure. Schiidel 
assumes that a branch of the first sacral nerve, which sup- 
plies the lumbar muscles, is involved in these cases. The 
muscles being instinctively relaxed the contraction of the 
muscles on the healthy side produces the deformity. 
Higier reports the case of a laborer who claimed that at 
one time during the paroxysms of pains the trunk was 
bent to the painful side and during the interval toward the 
sound side. No hypothesis has been advanced which will 
explain all cases. Higier's article is accompanied by a 
copious bibliography. Remak (Deutsche Med. Wochensch., 
No. 27, 1892) also reports a case of homologous scoliosis 
accompanying sciatica, but explains it by the position of 
the patient when at work (bent forward and to the affected 
side) and by unconscious efforts to assume the easiest posi- 
tion. The deformity vanished with the pain. 

G J. KAUMSEIMER. 

Vaso-Motor Neuroses. — Dr. Tomson has selected the fol- 
lowing from a number of allied conditions seen and noted, 
as they seem to form a somewhat definite series and to 
illustrate what he believes to be an extensive section of 
functional disorders, namely, local and general vaso-motor 
neuroses. From the standpoint of evolutionists, instability, 
of the highest nerve centres is due to their being the most 
recently evolved. Neurotic people are not dull and stupid, 
they are often keen and intellectual. Intellectual weakness 
has been transmitted with intellectual strength. The same 
disease may be transmitted with equal frequency. Another 
of the same class is representative of the faulty habit : a 
parent has migraine, the child epilepsy. In cases of hysteria 
major described by Charcot, we find such conditions as epilep- 
sy, drunkenness, hysteria and other diseases of same class in 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 165 

family histories of patients affected, showing a faulty nerve 
habit or neurotic tendency that is transmitted. Author 
here gives several cases to illustrate or prove this theory. 
One patient was subject to attacks of morbid blushing, same 
patient could not be confined in room without possibility of 
egress, as it would be certain to produce diarrhoea with 
watery evacuations. Another would secrete large quantities 
of pale urine and he would have an uncontrollable desire to 
micturate. Neither case shows any sign of bowel or kidney 
disease. Author thinks the large amount of pale urine due 
to an increase of blood pressure from a temporary dilatation 
of renal arteries. Another has visual sensations, apathy and 
languor, flushing of face, violent hemicrania, retching and 
vomiting. Three other cases have paroxysmal palpitation 
of the heart without organic disease. — (Lancet, Oct. 15.) 

B. M. CAPLES. 

Local Neurasthenias. — Dr. Weill (Revue Intern' t du 
Biblio. Med., Oct. 10, 1892) understands by local anaesthesias 
one or more functional disorders grafted on a cured organic 
lesion or due to a fortuituous cause, the neuropsychic effect 
of which alone remains. These may involve the viscera 
(heart, lungs, stomach, genitals, etc.) and are very curable 
by suggestion. 3t G . kiernan. 

Eye-Strain and its Relation to " Cerebral Hyper- 
emia," Etc., is the title of an article written by E. C. 
Seguin, M. D., for the New York Med. Jour., December 3. 
Eye-strain, more especially that due to paresis or weakness 
of the third and sixth cerebral nerves, produces many 
symptoms besides cephalalgia and migraine. Chief among 
these are: occipital, suboccipital and occipitocervical pain 
and distress; a sense of stiffness at the occipitocervical 
region; feelings of fullness, pressure or lightness in the 
head ; numbness or formication in the scalp ; dizziness 
(but not true vertigo) ; inability to read, write, converse, sit 
at table, or even to think without aggravation of symp- 
toms ; fear of certain places ; insomnia ; emotional attacks ; 
pains in various parts of the head ; and, later, the multiple 
symptoms termed neurasthenia. These symptoms, com- 
bined with others, have been appropriated by the advocates 
of a fanciful vaso-motor pathology, and such " diseases " as 
" cerebral hyper semia " and " congestion of the base of the brain " 
have been accepted by the profession with too little open 



166 neurological. [December, 

criticism. The author does not recognize these " diseases " 
but records the symptoms as cephalic paresthesia, and offers 
a partial grouping which may serve as a basis for a better 
classification. 1. The majority of cases presenting such 
symptoms are, he thinks, cases of eye-strain. Errors of 
refraction play but a secondary part in the genesis of the 
symptoms, whereas they are very important in cases of 
cephalalgia and migraine. Not rarely, the symptoms 
appear within a short time, or suddenly, after years of 
apparently easy use of the eyes. This sudden onset may 
often be traced to some debilitating influence. In other 
words, the strain of weak eyes is often rendered latent by 
perfect health. 2. Some cases of cephalic parsesthesise are 
due to dyscrasic conditions, more especially litbsemia, oxal- 
uria, latent gout, etc. 3. Such symptoms as lightness of 
the head, pressure in any direction, deficiency in power of 
attention, etc., may undoubtedly be caused by anemia of 
the brain from general anaemia or cardiac diseases. 4. It 
is also possible that these symptoms indicate the beginning 
of organic cerebral disease. 5. Probably some cases of 
cephalic paresthesia are developed by the action of periph- 
eral lesions. Dr. Seguin's chief purpose in this article is to 
advance the problem as presented in group 1 one step 
farther, and to state which of the symptoms may be caused 
by paresis of the third nerves and their muscles, and which 
by paresis of the sixth, apart from the element of refraction. 
A. Symptoms of Paresis of Third Nerves. — Occipito-cervical 
pain and " distress " are the characteristic symptoms, some- 
times the only ones. Pain is generally diurnal and often 
does not appear until patient uses his eyes in dressing, etc., 
and is usually greatest between occipital bone and second 
vertebra. There is never neuralgia of occipital nerves, nor 
objective rigidity. Tenderness is rarely found, although in 
women spinal hyperesthesia often coincides. Mental fail- 
ure is simulated in loss of volition. Symptoms are 
increased by any act requiring convergence. It is some- 
times said that symptoms appear or are increased by 
" simply thinking." When headache is present there are 
generally faults of refraction or other factors. Simple 
asthenopia is only occasional and seldom prominent. Usu- 
ally patient pretends to have strong eyes. B. Symptoms of 
Paresis of Sixth Nerve. — In contrast with symptoms of class 
A. these are different and less definite. Dizziness is most 
prominent, not true vertigo, but a sense of unsteadiness 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 167 

clearly referred to the head. Allied is a sense of indefinite 
fear. Peculiar sensations are felt in the head, fullness, 
pressure, pain in scalp, numbness, etc., and noises in the 
head, not ears, is not rare. As these parsesthesiae are 
increased by moving objects we often meet with conditions 
similar to agoraphobia and claustrophobia. Movements 
necessary to examination of eyes in these patients fatigue 
them greatly. Apparent loss of mental power is more 
marked than in cases of category A. In quiet of his room 
patient can do things fairly well, but in his relation to the 
world he loses self-control and power of concentration. 
Sometimes he is said to be hysterical and often hypochon- 
driacal. Insomnia and neurasthenia belong to both cate- 
gories. At this stage diagnosis is obscure. There is a certain 
overlapping of semeiology in this sketch of the two groups, 
but the author believes further study will make the distinc- 
tion more complete. Probably a special grouping of symp- 
toms will be found due to "spasm of accommodation." 
Diagnosis by Manipulation. — The simple test of convergence 
increases suffering of subjects of the first category, while 
those of the second experience great distress when made to 
look around without turning the head, or if a bright object 
be rotated before them. Complete atropinization gives 
these last patients great relief. Diagnosis by Drugs- — Bro- 
mide often enables us to judge cases correctly in which 
hysterical and epileptical symptoms are conjoined. Cases 
of the first category are relieved by nux vomica or strych- 
nine, and aggravated by belladonna and other mydriatics ; 
whereas the last named remedies give relief in cases of the 
second category, and strychnine makes them worse. Proper 
glasses, and in some cases partial or total tenotomy or myot- 
omy, are most important. The internal use of nux vomica, 
strychnine and nerve tonics generally, in cases of class A., 
and of cannabis indica, belladonna, atropine, conium, the 
bromides, antipyrin, etc., for those of category B. will be 
found most useful. In both, prolonged rest and general 
restorative treatment are necessary, and sometimes ocular 
rest by atropinization. Travel should never be prescribed 
until all visual defects are remedied and convalescence is 
evident. There are eyes which cannot be " corrected " with 
our present appliances and in such the prognosis is bad, 
although temporary improvement may be obtained by 
proper medicinal and hygienic treatment. Tobacco is par- 
ticularly injurious to persons whose third nerves are weak. 



168 neurological. [December, 

Implication of the Nerves in Leprosy.— A German, 
aged 40, who had spent several years in Siam among a 
leprous population, showed a distinct area of leprosy on the 
left arm. Above the elbow, two nodules as large as filberts 
were found and extirpated. From one of these a pro- 
longation extended to the median nerve, which was divided. 
The thickened nerve, as well as the nodule, contained a 
peculiar cheesy mass. This mass was found to occur 
throughout the entire course of the nerve. It was removed 
with a sharp spoon. No loss of function resulted ; on the 
contrary, some improvement of the anaesthesia took place. 
Later, similar nodules formed on the ulnar and internal 
cutaneous nerves with the same cheesy contents. The 
patient gradually regained the use of the arm. The cheesy 
mass contained leprosy-bacilli. The cutaneous nerve, which 
was excised, was infiltrated with them. — (Wien. Med. 
Wochensch.,^o. 31, 1892.) 



G. J. KAUMHEIMER. 



Unilateral Leg Pseudo-Hypertrophy from Influenza. 
— Dr. Annequin (Dauphine Med., July, 1892) reports the 
case of two young soldiers who, soon after recovery from 
influenza, experienced sharp, darting pains in the leg on 
attempting to walk. One leg grew rapidly in size and 
measured at its greatest width three centimetres more than 
the other. This lasted a great while. Electrical excitability 
and strength were diminished. 



J. G. KIERXAN. 



Acute Primary Hemorrhagic Encephalitis. — Dr. J. 
Schmidt reports a case of this rare disease observed during 
the influenza epidemic of 1889-90. Miss S., aged 19, of 
chlorotic appearance but otherwise healthy, complained, 
after an exciting round of social gayeties, of headache for a 
period of 8 or 10 days. Mar. 8 the headache became 
violent and was accompanied by vomiting. When first seen, 
Mar. 9, the only complaint was of general agonizing head- 
ache. No abnormality of the cranial nerves, viscera, pulse 
or temperature was elicited. In the evening an epileptic 
convulsion followed by slight somnolence occurred. On 
Mar. 10 the convulsions had become more frequent, longer 
in duration and more severe. The stupor had increased, 
P. 120, T. 39.6°C. The pupillary reaction had vanished and 
there was conjugate deviation of eyes and head to the left. 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 169 

There was no paralysis. Patellar reflex was present, 
plantar reflex weak, abdominal reflex absent. Death early 
in the morning of Mar. 11. Dr. Edinger, who examined 
the brain, reported as follows : The hardened brain was 
examined in sections. The head of the caudate nucleus on 
the left side was a single mass of bloody detritus which 
reached outward and downward deeply into the nucleus 
lentiformis. Farther back large and long fissures filled 
with blood were seen in the corpus striatum and anterior 
part of the capsule. At a level with the anterior third of 
the thalamus on the left side, a fissure 1.5 cm. long and 
filled with blood ran through the posterior limb of the 
capsule. On the left side the capsule, putamen and nucleus 
lenticularis, as well as the thalamus, were studded with 
punctiform hemorrhages. A number of hemorrhagic 
fissures were found in the ganglion of the right side. The 
right nucleus lenticularis was deeply stained with blood, but 
intact except at its posterior part which was converted into 
a hemorrhagic cavity. The tissue, dorsad and posterior to 
it, was a mass of bloody debris. While the capsule and the 
pes were extensively deranged, the remainder of the white 
substance and the cortex seemed free. A microscopic ex- 
amination was not made in view of the enormous disorgan- 
ization. — (Deutsche Med. Wochenschr., No. 31, 1892.) 

G. J. KAUMHEIMER, 



Anomalies of the Indirect Electric Excitability and 
their Relation to Chronic Plumbism. — 1. In the subjects 
of chronic plumbism certain changes in the electric 
excitability can be demonstrated, even in the absence of 
paralysis of the extensors. The reaction to the positive pole 
of the opening induction current first disappears, then the 
galvanic A. S. Z. 2. The loss of the indirect reaction for 
the positive pole of the opening induction current, and the 
anode closure of the galvanic current, are the earliest signs 
of a degenerative neuritis. 3. The investigation of these 
points should always be carried out in analogous cases. A 
series of concurrent observations would furnish an aid to 
the diagnosis of cases of insidious neuritis of typcial locali- 
zation. — (Dr. Karl Gumpertz, Deutche Med. Wochenschr. , No. 
33, 1892.) 

G. J. KAUMHEIMER. 



170 neurological. [December, 

Gastric Crises. — Riegel, at the Giessen Medical Society, 
showed a girl, twenty-seven years of age, who for five years 
had suffered from periodic attacks of vomiting which were 
severe in character and rebellious to treatment, lasting for 
days or weeks at a time. The earlier attacks were painless but 
later there was severe pain in the epigastric region. During 
the intervals she was perfectly well and no organic disease 
of any kind could be discovered. There is a suspicion of 
specific history. In many respects the case is similar to one 
reported by Leyden in which the attacks were found to be 
gastric crises, the result of posterior sclerosis. While gastric 
crises are not infrequently present in the first stage of tabes, 
it would be extremely rare to have them persist for five 
years without the development of further symptoms: — 
(Deutsche Med. Wochemchr., Oct. 6, 1892.) 



JOS. KAHX. 



Pathology of Old Age. — Dr. E. H. Grube, of Pittsburgh, 
says that in autopsies upon bodies of old people a large number 
of tubercular lesions are found which were not suspected dur- 
ing life. Active tuberculosis is not a prominent disease in 
old age, but is sometimes chronic. Dr. Grube does not 
agree with many other physicians that "pneumonia is the 
scourge of old age," and when this disease exists he does 
not consider the prognosis much graver than in youth, 
unless there be great debilhy from pre-existing disease. 
Two facts are worth noting in this connection: one, that 
defervescence by crisis is rare among the aged ; and the 
other, that muttering delirium is almost prognostic of a 
fatal termination. Changes in the alimentary canal are 
well marked in old age. Constipation is generally present, 
but sometimes there is a troublesome diarrhoea. Cancer, 
especially of the stomach and liver, is frequent. Bright's 
disease is apt to be chronic and is generally of a 
fibroid character and likely to be undiscovered in con- 
sequence, and the patient is treated for indigestion, 
rheumatism, etc. The most distinctly senile change is de- 
generation of the brain and nervous system. In the brain 
the sulci become shallower, the gray matter thinner, and 
the brain, as a whole, shrinks. This shrinking is com- 
pensated for by an increase of ventricular and subarachnoid 
fluids. Corpora amylacea appear in the thinned cortex. 
In the cord and nerve trunks many of the medullary 
sheaths disappear, giving the sections the appearance of 



1892.] THERAPEUTICS. 171 

being full of minute punctures. Conductivity of the nerves 
is lowered and there is gradual loss of mental power, mem- 
ory and attention suffering most. When these changes are 
exaggerated we have either softening or sclerosis, ending 
in dementia. (Medical Standard, December, 1892.) 



THERAPEUTICS. 

Labyrinthine Vertigo, with Especial Reference to its 
Diagnosis and Treatment, was the subject of a lecture by 
C. K. Mills, M. D., delivered at the Philadelphia Polyclinic 
Hospital. Often the chief complaint of a patient is of diz- 
ziness, giddiness or vertigo; less frequently of pitching, 
reeling or staggering. These terms may indicate the exist- 
ence of any one of a variety of diseases. Case in illustra- 
tion — male, aged 52. Two months ago had a sudden attack 
of what was pronounced " congestion of the brain." 
Patient did not fall, but everything looked dark. Quickly 
recovered, but had another attack of vertigo, reeling and 
nausea next day. In bed three weeks suffering from severe 
cephalalgia. Became totally deaf in left ear and partially 
in right; complained of great roaring in left ear. Now 
feels dizzy all the time. Has no paralysis nor impairment 
of common sensibility. Knee-jerk absent on left, but pres- 
ent on right side ; muscle-jerk about normal on both sides. 
Has fits of depression and often cries. Causes. — Four years 
ago had a sun-stroke which, apparently, did not leave him 
with marked symptoms of chronic intra-cranial disorder. 
Has recently recovered from the grippe, since which illness 
his hearing has been poor. With exception of lost knee- 
jerk on one side symptoms seem to point to the apparatus 
of hearing as the seat of the disease. Etiology of case is 
not positive. Patient has a history of sun-stroke and an 
infectious disease, each of which sometimes imitates forms 
of meningitis, and possibly labyrinthine otitis also. Such 
cases are not improperly called apoplexies, although the 
seat of the apoplexy is not in the brain but in some portion 
of the labyrinth. Patient may have bilateral labyrinthine 
hemorrhages with secondary inflammation. His condition 
is much improved under larger doses of iodide of sodium. 
The unilateral absence of knee-jerk in this patient is the 
only symptom pointing to cerebellar disease, as occasionally 
in lesions of the cerebellum knee-jerk cannot be obtained. 
It is not improbable, however, that serious irritative lesions 



172 neurological. [December,, 

of both labyrinths might so impress the centres of equilib- 
rium in the cerebellum that the latter would secondarily 
act to inhibit the spinal centres. An otitis labyrinthica, 
described by Voltolini, closely resembles meningitis; 
unconsciousness ensues early, but returns in two to four 
days. Staggering gait at -first which gradually disappears, 
but incurable deafness is left. Hearing is unquestionably 
affected by Meniere's disease, but a few cases have been put 
on record in which all symptoms except deafness were pres- 
ent. While aural vertigo usually means labyrinthine ver- 
tigo the labyrinth is not always the seat of the lesion, as 
inflammation may extend to it from other parts of the ear. 
It is best, therefore, to consider aural vertigo under the 
three forms of external ear, middle ear and internal ear 
vertigo. Following this classification the term, Meniere's 
disease, should be used to indicate vertigo of the third 
class. The prognosis of the disease is variable. A few 
cases, particularly those due to recent inflammation of 
small extravasations, can be practically cured. In some 
syphilitic subjects the early and active use of mercury and 
the iodides is strikingly successful. Indications for treat- 
ment are various and local conditions must be considered. 
If they point to chronic inflammatory disease not only of 
the labyrinth, but of the external and middle ear also, the 
treatment should keep this fact in view. Eustachian infla- 
tion and cauterization and any of the approved methods of 
treating otitis externa or media should be adopted in addi- 
tion to measures for reaching the labyrinth. Some sur- 
geons have met with success in removing the incus and 
malleus, also the products of chronic inflammation as far as 
possible. When syphilis is part of the history remedies 
like mercury and the iodides are distinctly indicated. If 
rheumatic or gouty diathesis be present, cathartics, alkalies, 
the salicylic compounds, calchium and lithia salts should 
be given a thorough trial. Charcot strongly advocates the 
use of quinine, giving the drug in large doses to the point 
of marked cinchonism, but discontinues it entirely after 
full cinchonism has been produced. Occasionally the use 
of the drug is dangerous. In connection with large doses 
of quinine there is sometimes a form of vertigo which is 
malarial in origin, the toxic agent probably acting upon 
the nervous apparatus of the labyrinth or upon the enceph- 
alic centres of equilibration. The salicylate compounds, 
particularly the salicylate of sodium, have been used in 



1892.] THERAPEUTICS. 173 

labyrinthine vertigo for a reason similar to that which led 
to a use of quinine. Gowers prefers the sodium to quinine 
and also believes the best effects are produced by moderate 
doses, as of live grains, three times a day. In connection 
with this disease the state of induced instability of the 
cerebellar or other centres of equilibration should not be 
overlooked. Remedies which are efficient in the reduction 
of cortical or ganglionic excitability, as the bromides, given 
in connection with the iodides sometimes relieve symptoms 
more quickly. Arsenic may be combined with the bro- 
mides. Belladonna, aconite, antifebrin, antipyrin and 
phenacetin may also be tried for their effects upon the 
centres and the circulation. A variety of remedies have 
been suggested for the relief of the vertigo and tinnitus of 
Meniere's disease, most of which are only of temporary 
benefit. Methods of balancing gymnastics may prove of 
service in some cases. Local treatment has sometimes a 
sensible basis for its use and great benefit has occasionally 
followed counter-irritation or leeching behind or below the 
ears. Charcot has recommended application of the cautery 
over the mastoid three or four times a week. — ( The Phila- 
delphia Polyclinic, September.) 



EXALGIN IN THE TREATMENT OF CHOREA. — Loewenthal, ill 

the Bed. Klin. Wochenschr., No. 5, 1892, reports a series of 
thirty-five cases of chorea treated with exalgin. The dose 
usually given was 0.2 gm. three times daily; occasionally it 
would be increased to 1.0 gm. a day. The powder was 
given dissolved in warm water sweetened with sugar. The 
age of the patients ranged from three to eighteen years. 
The course of treatment varied from eight days to four 
months. The cases that were placed upon the drug early 
answered well to treatment. In a few patients improvement 
was noticed after taking twelve powders, but more frequently 
after from twenty-five to thirty powders had been taken. 
The largest number of doses given a single patient was five 
hundred and sixt}^ The results achieved were good, but no 
better than those obtained by the use of the remedies 
ordinarily employed in the treatment of chorea. Nausea, 
vomiting, lassitude, headache and vertigo were noticed in a 
few cases. In three cases the patients became jaundiced. 
These were the only unpleasant symptoms noticed. — 
(Bielschoivsky, Neurologisches Centralblatt, No. 19, 1892.) 

JOS. KAHN. 



174 neurological. [December, 

Exalgin. — Although may eminent European physicians 
highly praise the effects of exalgin as a means of relieving 
pain, especially of the neuralgic type, Dr. W. C. Krauss, of 
Buffalo, takes issue with them on this point. Dr. Krauss 
has tried the drug in eleven cases without any beneficial 
result, and says that the friends with whom he has conversed 
upon the subject have had similar experiences. The doctor 
makes no effort to explain the variance between his observa- 
tions and those of eminent physicians, but simply wishes to 
protest against the almost unanimous verdict in praise of 
the drug accorded to it by most medical writers. (iV. Yl 
Med. Jour., Dec. 10.) 

Barium Chloride in Epilepsy. — In all so-called remedies 
for epilepsy there is something lacking, but barium chloride, 
in the opinion of Dr. J. D. Lisle, should be given a thorough 
trial. It is necessary to administer the drug by itself on 
account of its many incompatibilities. It possesses a bitter, 
astringent taste and causes a sensation of burning at the 
epigastrium. It excites active peristalsis of the bowels and 
copius alvine evacuations. The nervous system is stimulated 
and it slows the number of heart-beats, at the same time 
contracting the caliber of the arteries. Its action is similar 
to digitalis and ergot. The doctor concludes his article by 
giving the histories of two cases in which barium chloride 
very perceptibly lessened the number of seizures. (A r . Y. 
Med. Jour., Dec." 10.) 

Agathln. a new Axtixeuralgic. — Dr. E. Rosenbaum 
(Deutsch. Med. Ztg., Xo 50) reports on this substance which 
was discovered by Dr. J. Roos. It is a compound of 
salicylic acid and methyl-phenyl-hydrazin, and occurs in the 
shape of whitish flakes, insoluble in water, soluble in ether 
and alcohol, tasteless and odorless. After proving its 
innoccuity in animals it was administered to man in doses 
of 0.12 and 0.25 gm. without effect. Doses of 0.5 gm., 2 to 
3 times daily were more effective. A case of sciatica, which 
had been previously treated, was cured in 4 days. Rheu- 
matic affections were relieved by 4 to 6 gm. Dr. Laquer 
reports the cure of a very severe supraorbital neuralgia 
from the use of 6 gm. in 4 days, and a similar result in a 
case of influenza-neuralgia. Dr. Loewenthal has used it 
with success in neuralgias, as well as in rheumatism where 



1892.] THERAPEUTICS. 175 

the salicylates had failed. Dr. Rosenbaum reports a 
number of cases of neuralgia relieved or cured by this drug. 
(Wien. Med. Presse, No. 27, 1892.) 

G. J. KAUMHEIMER. 



Strychine and the Buccal-Lingual Mucous Membrane. 
— Wertheimer (Gaz. des Hop., Sept. 18, 1892) demonstrates 
that strychnine exerts a vaso-dilator action on the bucco- 
lingual mucous membrane. 



J. G. KIERNAN. 



Hydrastin, according to Egasse, (Bull, gtn de Therap., July 
30, 1892) is inferior to hydrastinine. Its action upon the 
vaso-motor is of short duration and feeble. Its action upon 
the heart is uncertain and dangerous. 



J. G. KIERNAN. 



Rhus Radicans in Children's Urinary Incontinence 
has been found useful by St. Phillipe (Jour, de Med. de 
Bordeaux, Aug. 14, 1892). He uses the tincture in five drop 
doses morning and evening. 



J. G. KIERNAN. 



Piperazine and Uric Acid. — Biesenthal, of Berlin, 
affirms that the concurrence of opinion is in favor of the 
use of piperazine in recent cases of gout, and that even in 
chronic forms its action is usually favorable. Continued 
small doses constitute a sure prophylactic. The remedy 
has proved valuable in renal colic and in hemorrhage from 
urinary tract. Last mentioned, when of year's standing, 
has been entirely relieved. (New York Med. Journal, Nov. 5.) 



C. M. CAPLES. 



Chloralamid. — In an article by Dr. Jos. Collins on chlorala- 
mid he speaks very highly of it as an hypnotic. The con- 
cluding portion is as follows : "So much can be said in 
regard to chloralamid, not alone in regard to its efficacy, but 
for the safety of its administration and the absence of 
symptoms produced by the ordinary hypnotics indicating 
the accumulation of waste products in the system, that the 
conclusion is forced upon us that in this substance we have 
an agency for the production of sleep which is deserving of 
our most sanguine expectations. That is does not replace 
the other hypnotics is a matter for congratulation, for in the 
treatment of this distressing symptom our armamentarium 



176 neurological. [December, 

cannot be too complete. In conditions where chloral is 
indicated but some intervening symptoms contra-indicate 
its use, such as weak heart and respiration, as in the asthenic 
stage of acute disease, or in diseases of the heart and lungs, 
chloralamid can be substituted with safety and with good 
results." 

The Therapeutic Utilization of Trional and Tetron- 
al. — As a result of extensive trials in Prof. Binswanger's 
clinic at Jena. Dr. A. Schaefer formulates the following con- 
clusions : "1. Trional and tetronal are of pronounced hyp- 
notic and sedative action. Tetronal seems to be somewhat 
more sedative than trional. The action begins within 10 
to 20 minutes. 2. Trional is a certain and prompt 
hypnotic in insomnia, and is indicated in the different forms 
of neurasthenia, in the functional psychoses and organic 
brain troubles. It has proved useless in cases of morphinism 
and cocainism and in cases where pain was present. 3. 
Tetronal is indicated as an hypnotic in those psychoses in 
which a moderate degree of motor excitement prevents 
sleep. 4. Xeither can be recommended in the severe 
psychoses with violent motor excitement. 5. The effective 
dose varies from 1 to 2 gin. but single doses of 3 to 4 gm. and 
daily doses of 6 to S gm. may be safely given. 6. They 
are best given at bed-time dissolved in milk or wine. 7. Xo 
deleterious action, except slight disturbance of the 
alimentary tract, has been noticed. 8. Unpleasant inci- 
dental effects were comparatively rare. 9. Even after pro- 
longed administration a withdrawal was not followed by 
unpleasant svmptoms. Habituation was not observed." 
[Berlin. Klin. Wochensch., Xo. 29. 1892.) 

G. J. KAUMHEIMER. 



Duboisine. — Dr. E. Belmondo (Rivista Sperimeniale, XYIII, 
II, 1892; reviews the more recent literature of duboisine 
which has appeared since the publication of his own paper 
in the preceding issue. From his review are taken the fol- 
lowing : Selvatica-Estense {La Terapia Jloderna, 1892, Xos. 
6 and 7) has employed duboisine in the psychiatric clinic of 
the University of Padua in twenty-two cases of various 
forms of psychosis and found it to produce quiet sleep, last- 
ing 6 to 8 hours, in all the cases. He employed it hypo- 
dermically, giving it in the evening, the natural hour for 
sleep, and Belmondo remarks that its hypnotic effects seem 



1892.] THERAPEUTICS. 177 

to have been the principal object of Selvatica's study. He 
himself considers this action of the drug as only secondary 
in importance ; its sedative action in states of psychic exal- 
tation, usually most violent in the day time, is superior to 
that of any other drug. Selvatica observed no bad effect 
on the pulse or respiration or any other injurious action, 
save in one case, of a hypochondriac in whom visual hallu- 
cinations and a state of motor unrest of short duration fol- 
lowed the injection of .0012 gm. of sulphate of dubois- 
ine. His maximum dose is the same as that recommended 
by Belmondo, viz., .0016 gm. and the minimum .0008. 
The paper of Selvatica is of interest further, in that it con- 
tains the results of a series of experiments as to the action 
of duboisine upon the circulation. Frogs, rabbits and dogs 
were the animals experimented upon and the results are 
summed up as follows : (1). Duboisine acts upon the heart 
similarly to atropine but with much less intensity. (2). It 
is an important vaso-motor agent, causing hyperkinesis of 
the peripheral vessels and dilatation of the central ones, by 
thus exerting a direct action on the heart. (3). Duboisine 
does not seem to be contra-indicated generally in cardiac 
disease as it lowers the blood pressure only within very 
restricted limits. It appears, therefore, indicated even more 
than atropia when there is a permanent slow pulse with 
vertigoes and syncope, and in arythmia, that preserve a 
sort of regularity in their succession and are not connected 
with organic disorders of the heart. Venanzia (II Morgagni, 
July, 1892) has tested duboisine in the Casa di Saluti 
Dufour, in Milan, and he also fully confirms the utility of 
this drug in controlling psychic and motor excitement of 
whatever grade or form. It is equally useful in mania, 
active melancholia, dementia agitata and neurotic insanity; 
and the author calls special attention to its slight utility in 
the expansive periods of acute or chronic encephalitis. 
Besides its calming effect in motor excitement, Venanzia 
observed that it seemed to clear up the intellect and after a 
fashion to regulate the ideation, a point noticed already by 
Belmondo. In a few patients Venanzia found a slight 
idiosyncracy as regards this drug, producing dryness of 
the mouth, thirst, anorexia or slight headache, ail of 
short duration. He makes a special point of its usefulness 
as a sedative, superior to all others in promptness and efficacy, 
and its only secondary value as an hypnotic. In insomnia 
of the so-called idiopathic form, and in the agrypnia that 



178 neurological. [December,, 

accompanies certain stuporous conditions, it is, indeed, of 
little value. The minimum dose, according to Venanzia, 
is about .0005 gram (=^{33 grain) to be increased gradu- 
ally to the maximum .0015 (= ]/& grain) or perhaps a little 
more. He finds these amounts sufficiently active. In 
France, also, the use in asylums of this drug has been 
recommended. At the third congress of French alienists 
at Blois, Mabille and Lallemant reported decided 
benefits from its employment in maniacal forms of insanity. 
They used hypodermic injections four hours before and 
after meals, beginning with .0005 gm. and not exceeding 
a total of .003 in the twenty-four hours. After six or seven 
days of the treatment they ad vised its discontinuance renew- 
ing it, if necessary, after a week. They found it effective 
in seventy-five per cent, of their cases and most so in 
females. They consider doses from .0005 to .001 gm. as seda- 
tive, above that as hypnotic. Belmondo criticises the large 
doses of the French authors and holds that such are liable 
to produce grave toxic symptoms. In conclusion, Belmondo* 
considers from all the evidence that we have a valuable 
therapeutic acquisition in this drug. He is inclined tO' 
hold, with Venanzia, that from its marked effect upon the 
psychic, and especially the intellectual functioning, it gives 
promise of being of special curative value in mental dis- 
orders. He also calls attention to another application of 
the remedy, not without value. From his own experience 
and that of Albertoni and Guilliarde, communicated to 
him by them, it appears to have the power to cut short 
almost at once the convulsive attacks of hysteria. 



New Uses for Sulphonal. — Sulphonal appears to have 
been of value in controlling such symptoms as reflex spasm 
and uneasiness following injury. Dr. Andrews speaks of 
sulphonal as a certain remedy in treatment of muscular 
cramps of legs appearing during night, and especially those 
accompanying fractures of long bones. Fifteen grain doses 
give immediate relief. Dr. Althos (Am. Jour. Med. Sci.) rec- 
ommends sulphonal for insomnia occurring in treatment of 
psychoses following influenza. 



B. M. CAPLBS, 



Sulphonal. — Von Salkowski, Jolles and Hamerston have 
found hsematoporphyrin in the urine of patients taking 
sulphonal, and they hold that it is directly caused by its 



1892.] THERAPEUTICS. 179 

exhibition. This conclusion was natural because heemato- 
porphyrin had been found in the urine but seldom, and 
outside of sulphonal nothing was known to produce it. 
Certain experiments would indicate, however, that these 
observers are mistaken. Sulphonal has been given to dogs 
in gradually increasing doses until death resulted, but in no 
case did the urine contain hsematoporphyrin. In man, after 
the drug has been given in large quantities for many months, 
the urine shows the presence of haematoporphyrin in but a 
comparatively small number of cases. More recently a 
number of cases of hsematoporphyrinuria have been re- 
ported in which sulphonal had not been used. Garrot finds 
that it is not uncommon in arthritis and in chorea, and 
reports fourteen cases in which sulphonal had not been 
given. It is possible that sulphonal produces haemato- 
porphyrinuria in cases in which a predisposition already 
exists, just as salicylic acid may produce albuminuria 
when the kidneys are already affected. It is safe to say 
that where haematoporphyrin is found in the urine after 
the moderate use of sulphonal, the trouble is not due to 
the toxic action of the sulphonal alone. (F. Goldstein, 
Deutsche Med. Wochensch., Oct. 27, 1892.) 

JOS. KAHN. 



Two Cases op Tetanus treated by Antipyrin. — Cavina 
and Venluroli record two cases in which administration of 
antipyrin in large doses seemed to contribute largely to 
ultimate recovery of patients. Chloral was given at same 
time but authors think that drug not the essential part of 
the treatment, for the spasms were only modified so long as 
the antipyrin was taken and recurred when chloral alone 
was given. Other cases have been reported in which 
antipyrin was successful in tetanus, and it may well be that 
even if it be not actually curative, it does good by enabling 
the patient to live through what would otherwise be the 
fatal course of the disease while the toxin is being 
eliminated by the ordinary method. (British Med. Journal,. 
Oct. 15.) 

B. M. CAPLES. 

On a Method of Curing Evident Experimental Rabies. 
— Tizzoni and Centanni report the results of experiments 
upon the treatment of experimental rabies at a time when 
its symptoms are plainly evident. Tizzoni, in a previous 



180 neurological. [December, 

paper, has reached the following conclusions: 1. The 
blood of immune animals will prevent the occurrence of 
rabies if injected either before, or within 48 hours after 
infection. 2. The action of blood serum is that of a true 
internal disinfectant, destroying the virus present in the 
organism. Later experiments showed that the serum of 
immune rabbits, administered to infected animals from the 
seventh to the fourteenth day by either hypodermic, intra- 
vascular, or peritoneal injection, would cause the disappear- 
ance of all symptoms, the animals remaining well at periods 
varying from 75 to 145 days. The quantity administered 
varied from 11 to 26 ccm., in doses of 3 to 5 ccm. Control 
experiments showed that the cords of animals infected on 
the sciatic nerve possessed virulent properties on the 
seventh day. By special methods, of which a more 
extended report is promised, the authors succeeded in 
obtaining from the cord of rabid animals an immunizing 
substance. This substance will prevent the appearance of 
rabies in inoculated animals as by the Pasteur method, but, 
like it, will not cure pronounced rabies. The authors are 
anxiously awaiting an opportunity of testing this therapeutic 
measure upon a human being. (Deutsch. Med. Wochenschr., 
No. 27, 1892.) 

In No. 30 of the same journal the authors publish further 
reports on the same subject. The curative substance was 
obtained from the serum of animals which had proven 
refractory to subdural or endovenous inoculation and were, 
consequently, thoroughly immune. The serum was mixed 
with 10 volumes of absolute alcohol and the resulting precip- 
itate dried in vacuo over sulphuric acid. The precipitate 
from 14 to 21 ccm. of serum, weighing between 0.9 and 
1.30 gm., was given in 5 or 6 doses dissolved in a small 
quantity of sterile water. This gave a yellowish gummy 
fluid. The experiments were practically identical with the 
previous ones. The injections were never made before the 
seventh day. The animals so treated were living from 60 
to 80 days after infection. The control animals died of 
rabies between the sixteenth and the twentieth day. This 
precipitate, dissolved in water, will also destroy the virulence 
of the cord of a rabid dog mixed with it in a test tube. No 
attempt was made to determine a minimum dosage. The 
dosage in man must be determined by direct experiment. 

G. J. KAUMHEIMER. 



1892.] THERAPEUTICS. 181 

Untoward Effects of Nervous Transfusion. — Dr. 
Grand-Clement has, following Dr. C. Paul, used (Mercredi 
Med., August 10, 1892) injections of nervous substances in 
neurasthenia. He gave six injections during six days; 
three in the left lumbar region and three in the internal 
aspect of the left fore-arm. After each of these injections 
there had resulted a sort of semi-paralysis of the member 
of the side injected. The fore-arm flexors had lost some 
contractile force, and this loss diminished gradually. There 
was no constitutional benefit. 

J, G KIERNAN. 

Treatment of Epilepsy and Neurasthenia by the Sub- 
cutaneous Injections of Normal Nerve Substance. — Prof. 
V. Babes, of Bukarest, has noticed that several patients who 
had been treated with Pasteur's antirabic virus reported 
that various nervous troubles, as neurasthenia, epilepsy or 
hysteria, had ceased or become much milder. He himself 
and an assistant, who had used the inoculations prophy- 
lactically, had been relieved of pronounced spinal neuras- 
thenia after their use. Assuming that the nerve substance, 
and not the virus, was the cause of the improvement, further 
experiments were made on two neurasthenic persons with 
gratifying results. A patient with beginning locomotor 
ataxia reported relief of pain, although great excitement, 
pollutions and other symptoms of irritation supervened. At 
this time Dr. Constantin Paul, of Paris, became acquainted 
with the method, which w T as turned over to him for system- 
atic clinical trial. In his report to the French Academy 
of Medicine, Paul calls it " ' le procede du Prof. Babes ". 
Babes' method differs somewhat from that of Paul's. Babes 
presses the carefully obtained cord and brain through 
several layers of earthenware and prepares an emulsion of 
the resulting liquid with five parts of bouillon. Paul mixes 
the material with glycerine and filters under pressure of 
C0 2 . Extreme asepticity is necessary. The neurasthenic 
patients received four or five, the epileptics five or six injec- 
tions weekly. The dose of the emulsion (one to five) was 
from four to five gm., injected under the skin of the abdo- 
men and sides. Babes gives clinical histories of ten cases of 
neurasthenia which improved with surprising rapidity. 
Adjuvant treatment was used as with other methods. One 
of his assistants was cured of a sciatica of a month's stand- 
ing by three injections. A case of severe progressive lype- 



182 neurological. [December, 

mania recovered after ten injections. Locomotor ataxia, 
Jacksonian epilepsy and myelitis were not benefitted and 
sometimes made worse. One light case of tabes was, how- 
ever, benefitted. He then gives the histories of six cases of 
epilepsy, two adults, two adolescents and two children. The 
duration was from one to fifteen or more years, the fre- 
quency of the fits varied from once a week to seven or eight 
per day. Improvement was prompt in all cases. Eleven 
other cases in which the fits occurred at greater intervals, 
are still under observation. Babes believes the good results 
to be due to the introduction of a quantity of extractive of 
the brain and cord, stimulating the nerve centres to a regu- 
lar healthy action. He protests against the identification 
of his method with that of Brown-Sequard. (Deutsche Med. 
Wochensch., No. 30, 1892.) 

G. J. KAUMHEIMER. 

Testicle Juice in Therapy. — Deponx (Mercredi Med., 
Oct. 26, 1892) reported, at a recent meeting of the Paris 
Biological Society, the case of an officer who had been 
prematurely retired because of luetic locomotor ataxia. 
There were decided symptoms of the neurosis when the 
patient came under Dr. Deponx's care. Under hypoder- 
matics of testicular juice the symptoms disappeared and he 
could be regarded as having recovered. The pupillary re- 
action to light was rather indolent. The gait had become 
seemingly normal. Brown-Sequard said that the case was 
confirmatory of several he had reported. The knee-jerk 
often in such cases remained absent, but this was not of the 
grave significance ordinarily assigned to it. Dr. Brown- 
Sequard had observed the case of a much depressed female, 
far advanced in pregnancy, whose foetus had ceased its 
movements. Hypodermatics of testicular juice not only 
caused decided improvement in the mother, but the foetal 
movements rebegan and exceeded their previous intensity. 



J. G. KIERNAN. 



The Treatment of Myxcedema. — In the Eivista Sperimen- 
tale di Freniatria e di Medicina Legale, XVIII, II, Aug. 15, 
1892, Giulio Vassale critically reviews the recent literature 
of the treatment of myxcedema by injections of the thyroid 
juice. The papers of Murray Fen wick and Beatty were 
noticed in his own former memoir and the following later 



1892.] THERAPEUTICS. 183 

publications are here reviewed by him. Carter (Brit. Med. 
Jour., Apr. 16) reports a case of myxcedema and insanity 
treated with injections of extract of the thyroids from the ox 
and pig. The patient was a married woman, 43 years of 
age, who, with all the typical symptoms of myxcedema, was 
subject to periods of severe maniacal excitement. The 
patient had been four years in the asylum. The injections 
were first given Oct. 21, 1891, and were kept up, twice a 
week, till Feb. 7, 1892. After the fourth injection the patient 
appeared calmer, and after the sixth the facial expression 
was improved and the skin seemed nearly normal. At the 
end of 1891 the physical symptoms of myxcedema had 
nearly disappeared and the speech was normal. Although 
the effect of the injections was mainly on the bodily condi- 
tion there was also some mental improvement. The author 
publishes pictures of the patient before and after treatment, 
illustrating its effect. A case of myxcedema, wonderfully 
benefitted by injections of thyroid extract, was presented to 
the Clinical Society of London by Davies (op cit.) on the 22d 
day of April, 1892. Macpherson (Edinb. Med. Jour., No. 5, 
1892) describes the case of a woman, aged 39, suffering from 
myxcedema and treated by thyroid grafting. The disease 
was of three years standing and the mental syndrome was 
that of stuporous melancholia with terrifying hallucinations. 
Extremities cold and cedematous, refusal of food, marked 
lethargic tendency, movements sluggish, tendon-reflexes 
exaggerated. The face had a waxy look, the tongue was 
enlarged and flaccid showing the dental imprints, and speech 
was difficult. Supra-clavicular oedema marked, hair and 
nails characteristic of the disease, extreme anaemia and head- 
ache. The menses appeared every fifteen days and lasted a 
week. The urine was scanty. The author obtained a lobe 
of the thyroid from a freshly killed sheep and dividing it 
into two parts he grafted each of them under the skin in 
the infra-mammary region of each side. The improvement 
of both mental and bodily symptoms was rapid and pro- 
gressive. Speech became fluent, the melancholia and head- 
ache and the terrifying delusions all disappeared. The 
anaemia and dysmenorrhea likewise disappeared, and the 
skin took on its normal condition. The improvement is 
credited to the absorption of the thyroid juice rather than to 
the assumption of the functions of the gland by the 
transplanted portions. Brown-Sequard and D'Arsonval 
reported to the Academy of Sciences, Paris, June 13, 



184 neurological. [December, 

1892 (Semaine Med., June 22, 1892) the cases of two 
subjects of myxcedema in the service of M. Bouchard, 
treated by the injections of the thyroid juice, with the 
result that scarcely any traces of the disorder remained 
after ten days treatment. On July 2, Brown-Sequard pre- 
sented to the Soc. di Biologie in the name of Dr. Chopinet, 
a case of myxcedema cured by these injections. The disease 
was of many months duration ; the treatment was begun in 
December, 1891. By an anatomical error the thymus gland 
was substituted for the thyroid at first and no results 
obtained, the morbid bodily symptoms increased, and by 
March, 1892, were very pronounced. The mind, however, 
suffered little, only a slight loss of memory and quick 
fatigue of the brain rendering prolonged efforts at reading 
or conversation painful were observed. The facial expres- 
sion, nevertheless, was that of hebetude, due to the infiltra- 
tion of the tissues. In April, treatment with massage and 
the continuous current was instituted, with the result of 
reducing the swelling of the limbs, but the skin of the head 
and neck became more thickened and the attacks of feeling 
of oppression more frequent and severe. Having by this 
time found out the mistake previously made it was 
determined to reinstitute the former treatment by hypoder- 
mic injections. The first injection of thyroid juice was 
made May 2 and the treatment was continued till June 20. 
By May 10 improvement was under way, the tumefaction 
of the face, scalp, lips, eyelids, cheeks, tongue, etc., was 
lessened. The speech, mastication and deglutition became 
easier, the attacks of oppression less frequent and severe 
and had ceased completely by June 1. The appetite and 
digestion improved. On June 21 the patient's condition 
was altogether changed, physiognomy and expression almost 
normal, the speech and deglutition unembarrassed. Gley, 
at the session of the Soc. de Biologie, July 16, 1892, called 
attention to the effects of thyroidectomy in animals as induc- 
ing many of the lesions of myxcedema, and referred to the 
case of a woman in Bouchard's clinic that had come under 
his observation, probably one of the same noticed by 
Brown-Sequard and D'Arsonval. Charrin, confirming the 
observation of Gley, added that the woman in question was 
greatly benefitted by hypodermic injections of thyroid juice 
from the ox in aqueous solution with boric acid or naphthol. 
This improvement consisted not merely in relative changes 
in subjective phenomena, (memory brighter, less pain in 



1892.] THERAPEUTICS. 



185 



movements, less sensibility to cold, speech easier) but also 
in visible objective symptoms. The interruption of the 
injections suspended the improvement. Recently Dr. 
Breck (Jour, de la Soc. Regale des Sci. Med. de Bruxelles, 1892) 
has published the account of a case of a young woman, 
aged 24, treated by this method. The disease dated back 
many years and all the bodily symptoms of myxcedema 
were associated with grave psychic symptoms. In all, 
twenty-eight injections at varying intervals (the least three 
days) were made between Jan. 3 and May 10, 1892. The 
bodily symptoms showed the greatest improvements under 
this treatment. After the third injection the diuresis was 
considerably augmented and the patient at the same time 
complained of thirst. The oedema disappeared completely and 
the weight diminished nine kilograms. The osseous prom- 
inences reappeared, the expression became more intelligent, 
the attitude changed as did also the appearance of the hair, 
which became normal. The skin, at first pale, became 
ruddy. In a psychic point of view the improvement was 
much less evident, still a notable change for the better was 
observable. The affective feelings were awakened, the 
patient appreciated the reason of correction and promised 
improvement, ceased to be untidy and regained control of 
defsecation and micturition. The extract used by the author 
was prepared according to the direction given by Murray. 
The thyroid was carefully cleaned from its connective andi 
adipose tissue with aseptic instruments, and then cut into 
small pieces with scissors. These are put into a sterilized 
test tube with two cubic centimetres of a mixture of equal 
parts of a weak solution of phenicacid (0.5%) and glycerine, 
and left for twenty- four hours in a cool place. After this 
the solution is filtered and strained through a fine cloth previ- 
ously sterilized. In this way are obtained about three cubic 
centimetres of liquid which is used for two or three injec- 
tions at varying intervals, the minimum two or three days. 
Prepared in this wey the liquid seems to have a very 
decided effect, which is not lessened by the small quantity of 
phenic acid. The genuineness of the action of the thyroid 
extract seems to be beyond question clean from any suspi- 
sion of the action of suggestion, to which the effects of 
other animal extracts have been referred. The observa- 
tions upon the human subject fully confirm the result of 
experiments upon the lower animals, and indicate that we 
have in the extract of the thyroid gland a remedy for a 



186 neurological. [December, 

disorder hitherto rebellious to treatment. As to the inter- 
pretation of this beneficial action, Vassale suggests that the 
thyroid acts by transforming the products of tissue change 
and making them easily eliminable. The recent researches 
of God art and Slosse {Jour, de la Soc. Roy ale des Sci. Med. de 
Bruxelles, 1892) support this view. These authors, under 
the direction of Prof. Heger, made fistulse into the tho- 
racic duct of large dogs and collected the lymph that flowed in 
a giyen time, then after an injection of thyroid juice they 
again collected the lymph, the conditions of the experiments 
being always the same. The quantity and quality of the 
lymph are altered from the first minutes after the injection 
and take on their primitive character only after a variable 
period. The thyroid juice, therefore, is a lymphagogue sub- 
stance, analogous to those of Heidenheim. That physiologist, 
as is known, demonstrated that the production of lymph is 
not brought about solely by filtration, but that there are certain 
substances, for example the extract of crab muscle, that 
cause an increase of the quantity of lymph that passes from 
the blood for the tissues; the tissue elements are bathed 
more abundantly in the liquid and the amount of lymph 
flowing from the thoracic duct is increased. Other sub- 
stances, urea, glucose, iodide of potash, likewise cause an 
increase but in a different way, as they draw the water from 
the tissues and cause it to be eliminated, either indirectly 
by way of the lymphatics, or directly by the veins, thus 
causing increased diuresis. The thyroid juice will belong to 
this second order of lymphagogues of Heidenheim. Urea 
(a lymphagogue of this second order) also, according to 
Vassale's experiments, exercises a beneficial influence in 
thyroidectomized animals. As regards the treatmeut of 
myxcedema the question arises, which is the better, the injec- 
tions of the extract, or transplantation of the thyroid sub- 
stance itself? According to Macpherson the latter is prefer- 
able. By it we have the same benefit as with the injections 
and the chance that a small part of the gland, if not all, 
may attach itself and enter into function, thus supplying 
the system's needs. This last consideration alone is enough 
to give it the preference. The grafting of the gland into 
the peritoneal cavity, and more especially between the fascia 
and the the peritoneum, has been successful in animals 
(Eiselberg, Berliner Klin. Wochensch., No. 5, 1892). The 
transplantation subcutaneously of glands belonging to dif- 
ferent species is naturally much more difficult. In spite of 



1892.] THERAPEUTICS. 187 

all precautions suppuration is liable to take place, as occurred 
with Macpherson. There are, therefore, some dangers in the 
procedure. In the injections, on the other hand, with fresh 
material and proper antiseptic precautions the dangers are 
insignificant. If taken in the beginning there is reason to 
hope that the morbid process that led to the partial atrophy 
of the gland may be arrested, and the disorder completely 
and permanently cured. In a more advanced stage of the 
malady not all the symptoms (psychic) can be completely 
relieved. The nervous system may have so long suffered 
from the injurious influence of the suppression or deficiency 
of the thyroid function that it cannot fully recover, and it 
may be that the alteration of the gland is such that it can 
never take on again its functions. The effects of the injec- 
tions in these cases can be expected to be only partial or 
transient. 

H. M. BANNISTER. 

The Treatment of Nervous Diseases by Mechanical 
Vibrations. — Charcot observed that patients afflicted with 
paralysis agitans were greatly relieved by taking long 
journeys on the railway or by driving ; has had a mechan- 
ical arm-chair constructed that gives the same motion as a 
'railway carriage when the train is running. After passing 
a short time in the chair the patients sleep peacefully, the 
trembling disappears, and stiffness in movements ceases. 
(British Med. Jour.) 

B. M. CAPLES. 

SURGERY AND TRAUMATIC NEUROSES. 



Brain-Surgery. In The Medical News for December 3 
and 10, Dr. Roswell Park gives the histories of several cases 
upon which he operated, and summarizes his convictions 
and reflections upon brain-surgery as follows : " 1st. We 
have not yet learned the possible limits of brain-surgery, 
so-called, or the possible limits to which we may with 
reasonable certainty interfere with the functions of the 
brain or its component parts. Final knowledge in this 
respect will come rather through clinical experience than 
through experimental investigation. 2d. I have had a 
number of brain cases whose history shows that at the time 
of reception of injury the symptoms were so serious and 



188 neukological. [December, 

severe as to lead the medical attendants to consider the case 
hopeless, so that practically nothing was done. I wish to 
say all I can to condemn this apathetic course, and to urge 
that the most desperate case be attended to at once, with 
the same attention to detail as though it were quite hopeful 
in its outlook. 3d. In many of my own cases, and my 
experience is like that of many others, the mental or other 
disturbance that has finally led to operation has been 
allowed to run along, often for years and years, and patients 
have been brought to the surgeon only as a last resort. 
This course is as unwise in these cases as when we deal with 
malignant disease, and the profession generally should 
learn that the prognosis would be much more favorable in 
such cases were they operated upon when these disturbances 
first make their appearance. 4th. Personal experience has 
convinced me that when I have erred in operating for 
epilepsy or psychic disturbance, it has rather been on the 
side of doing too little than too much. For instance, in 
one of the cases alluded to under the caption Epilepsy, in 
which no improvement was manifested, I am now sorry 
that I did not take out so much of the arm-centre as to 
produce at least temporary paralysis of the arm. In other 
words, I have never regretted doing too much, but in several 
cases have regretted not doing more than was done. 5th. 
I wish again to insist upon the necessity of long-continued 
medicinal and dietetic treatment after these cases have 
passed out of the hands of the surgeon." 



Two Very Large Cerebral Tumors. — Case 1. A man, 
aged 29, came to Prof. Hitzig's clinic complaining of intense 
headache on the right side of the forehead since the sum- 
mer of 1891. This he attributed to a fright he had 
received some time previously but later admitted that he 
had been struck. In October, 1891, while in a tavern his 
cigar dropped from his left hand and his face was drawn to 
the left. Since then he had had four or five similar attacks 
followed by a slight, though distinct, weakness of the left 
hand. The left leg was not involved. In November the 
headache increased and he complained of visual difficulty 
which he very accurately described as a right temporal 
hemianopsia. Examination, later, showed only a very great 
contraction of the visual field and choked disc. Vomiting 
had never occurred. April 21, 1892, when first seen, the 






1892.] SURGERY AND TRAUMATIC NEUROSES. 189 

head was held to the left and forward. Pupillary light 
reflex slow, the accornodative reflex was better. The facial 
muscles on the left side were paretic as well as the left arm, 
and, in a slighter degree, the left leg. Patient was decidedly 
stupid. Sensation was normal. The patellar reflex was 
increased, especially on the left side, which also showed 
ankle clonus and increased skin reflexes. The region of 
the right temporal muscle was swollen, doughy and tender. 
The pulse was normal or even a little fast. Prof. Hitzig 
diagnosed a tumor of the right frontal lobe and referred 
him to Prof. v. Bramann for operation. The bone was found 
to vary in thickness, being in some parts as thin as paper, 
in others 1 cm. thick. In order to remove the tumor an 
opening, measuring 11 cm. vertically and 9 cm. horizon- 
tally, was necessary. The tumor, which was surrounded by 
healthy brain, was shelled out by the finger. Prof. v. Bra- 
mann said his finger entered the lateral ventricle. The 
patient recovered from the operation promptly, being but 
little worse than before but certainly with a longer expecta- 
tion of life. The tumor, which was a mixed sarcoma, 
weighed 280 grammes, while Hitzig assumes for the cerebral 
hemisphere a weight of 640 grammes. Case II was that of 
a man, aged 47, who had received a blow on the head one 
and one-half years before. The symptoms were, in general, 
those of a tumor of the right motor region. On December 
27, 1891, Prof. v. Bramann removed a, cyst the size of a 
duck's egg, which proved to be a portion of an infiltrating 
cystosarcoma. Large masses of the tumor were removed at 
two subsequent operations. July 8, 1892, both patients 
were alive. (Berlin. Klin. Wochensch., No. 29, 1892.) 

G. J. KAUMHEIMER. 



Craniectomy in Idiocy. — Dr. E. Regis (Jour, de Med. de 
Bourdeaux, July 31, 1892) reports three cases in which crani- 
ectomy had good results in idiocy. He strongly advises the 
transference of such patients after their recovery to an 
idiot school for special training. 



J. G. KIERNAN. 



Paracentesis in Syringomyelia. — Drs. Abbe and Culey 
report the case of a man presenting incomplete spastic 
paraplegia, specially localized, pathic, thermic and tactile 
anaesthesia and allochiria, the complex symptoms suggest- 
ing the existence of partial transverse myelitis below the 



190 neurological. [December, 

level of seventh dorsal vertebra. Exploratory operation 
disclosed a fusiform enlargement of cord between eighth 
and eleventh dorsal vertebra. After one and one-half 
drachms of a clear watery fluid was withdrawn the swollen 
cord collapsed. Recovery from operation complete. At 
end of second week spasms and rigidity of legs diminished 
and some control over bladder and rectum was regained. 
There was no further relief. Death occurred six months 
later. (Jour. Nervous and Mental Diseases, July.) 

B. M. CAPLES. 

Operative Treatment of Compression op the Cord Due 
to Dislocation of the Vertebrae. — A temporary resection 
of the spinal cord has twice been successfully done in 
Thiersch's clinic. After the muscles are loosened the 
arches are divided with a chisel close to the body. The 
cord can then be pushed aside and the projecting body 
chiselled off. The cases were of six and nine months dura- 
tion, respectively. Prompt resumption of function followed, 
except that in the first case the muscles of the right thigh 
remained paralyzed. In two cases of spondylitis which had 
run their course, the result was negative. Israel states that 
in some cases he does not attempt accurate replacement of 
the bones, in order to allow the cord to expand. (Deutsche 
Med. tVochenschr., No. 33, 1892.) 

G. J. KAUMHEIMEB. 

The Surgical Treatment of Contractures is the sub- 
ject of a paper read before the Brooklyn Surgical Society, 
by A. T. Bristow, M. D. Although most physicians be- 
lieve these contractures to be irremediable, the author 
differs from them in thinking that much may be ex- 
pected from surgical interference. He classifies the cases 
broadly as being cerebral, spinal or peripheral in origin. 
The first class is largest among children, and, while usually 
following birth-palsy, is also secondary to lesions developed 
during childhood. The second class consists of cases that 
result from sclerosis, either in the lateral or anterior columns. 
(Contractures following anterior polio-myelitis are not here 
considered.) The lateral-column sclerosis producing active 
spasm and contracture form about forty per cent, of the 
whole number of cases in infantile spinal paralysis of 
sclerotic origin, and for these it is necessary to put in a plea 
for the surgeon. The few cases following injury to a nerve 



1892.] SURGERY AND TRAUMATIC NEUROSES. 191 

trunk form the third class. The author believes in divid- 
ing all structures that offer resistance to free joint-motion, as 
medical treatment, whether in the form of drugs or elec- 
tricity, is useless, and it is futile to expect relief of contrac- 
tures in spastic cases from the use of apparatus while the 
spasm and contracture persist. In considering the advisability 
of operation four questions must be answered by the sur- 
geon : 1. Is relief possible in other ways? 2. Does the 
operation endanger life? 3. If unsuccessful will it render 
the condition of the patient worse than before ? 4. How 
permanent is the relief expected as a result? The first 
three questions may be answered in the negative. The few 
cases upon which the author performed tenotomy and myot- 
omy did not relapse. He does not claim that tenotomy or 
any other operation can restore histologic elements of the 
brain or cord that have been strangled by sclerotic processes, 
but the deformities that result therefrom can be relieved. 
The contractions are primarily due to central lesions, yet 
may it not be possible that their permanence depends upon 
the altered nutrition of the muscles themselves? Muscles 
that have long ceased to respond to volition have, under the 
influence of strong emotion, suddenly answered when called 
upon. If unconscious repair can take place in non-spastic 
cases, it is evident that in the spastic cases an organic con- 
tracture with coexistant spasm is an insuperable obstacle to 
the exercise of muscles that might otherwise respond to 
volitional impulses. The irritative processes set up by the 
primary disease may subside, yet, because of structural 
changes in the muscles, spasm and contracture still exist. 
Dr. Bristow gave the histories of three cases illustrating his 
classification. Case I had been attacked with lateral-column 
sclerosis at the age of three ; at eleven years of age had con- 
tracture of the gracilis, semi-membranosus and semi- 
tendinosus of both sides, as well as both gastrocnemii and 
peroneals. An attempt to walk brought on intermittent 
spasm of all these muscles and it was impossible for him to 
straighten the legs at the knee. The doctor divided tendons 
of all contracted muscles, twelve in number, one year ago. 
Operation was subcutaneous and recovery uneventful. 
Spasm and ankle clonus have not returned and child is able 
to walk a little on crutches. He also stands upright and 
improvement is on the increase. Case 2 belongs to the 
cerebral-spastic class. Boy, aged sixteen, had contractures 
from hemiplegia, the muscles chiefly affected being the 



192 neurological. [December, 

flexors of wrist and fingers. Dr. Bristow performed an open 
operation upon the flexors carpi ulnaris and radialis, split- 
ting and suturing their tendons. Wrist has remained 
straight and contractures have not returned during the two 
months since operation. Case 3 was a main en griffe result- 
ing from gunshot wound destroying ulnar nerve, with con- 
sequent wasting of the interossei and remaining muscles 
supplied by that nerve. Curiously, however, there was con- 
tracture of the flexor carpi ulnaris. This was divided and 
wrist straightened, but permission was given to divide only 
the tendons of the middle and ring fingers. This was done 
with perceptible gain, still, although vincula had also been 
divided, these fingers could not be entirely closed. This 
case was of eight years standing and probably further 
closure of fingers was prevented by adhesions or altered 
joint relations. Dr. Bristow concludes as follows : "Finally, 
1 do not bring forward tenotomy in these cases as the one 
and only thing necessary to a cure. With the relief of 
the contracture and deformity the real treatment may 
be said to commence. This is the foundation stone. It 
is absolutely essential, but it is only the beginning of the 
treatment. Afterward, electricity, massage, suitable pros- 
thenic apparatus, all have their proper places and uses. 
Without them the case will almost certainly relapse into its 
previous helpless condition even though the contractures do 
not return. I am confident that with tenotomy and appro- 
priate after treatment there are few of these cases that 
cannot be at least greatly improved. Absolute cure we can 
expect in very few." {The Medical News, Oct. 15.) 



Changes in the Nerves and Spinal Cord after Am- 
putation. — Marinesco reviews the literature of the subject, 
including observations on the human body as well as on 
animals, and reports three cases with autopsies from which 
he draws the following conclusions: I. After amputating 
a limb or making sections of nerves, pathological changes 
take place in the central portion of the nerves. The inten- 
sity of the changes depend upon the age of the animal and 
the time it is allowed to live after the operation. II. The 
anatomical changes resemble the Wallerian degeneration, 
which is surprising because the nerves are still in connec- 
tion with their trophic centres. The degeneration in the 
peripheral ends of nerves begins much earlier than in the 



1892.] SURGERY AND TRAUMATIC NEUROSES. 193 

central ends. III. The cause of the degeneration must 
probably be looked for in the severance of connection be- 
tween the centre and the periphery. We can easily im- 
agine that stimulation of sensory nerves produces biological 
changes, probably of a chemical nature, in the spinal gan- 
glionic cells which have a trophic influence upon the centres 
of the motor nerves. IV. When a limb is amputated or a 
nerve severed, this normal stimulus of the sensory nerve be- 
comes changed in quality and quantity and is no longer 
able to produce the proper changes in the ganglia. Thus a 
slow but constantly progressing change takes place in the 
efferent nerves. V. The nerve endings of sensory nerves 
contain no trophic centres, hence they, too, degenerate when 
they are cut off from the spinal cord, although they show 
more resistance than the motor nerve endings. VI. The 
order in which the different sensory and motor nerves de- 
generate is not easy to determine, although it probably de- 
pends upon the resistance of the individual nerve fibers. 
VII. The fibers which connect the spinal ganglia with the 
cord degenerate for the same reasons as do the central ends 
of the cut nerves. This explains the atrophy of the sensory 
portions of the cord. The difference in the character of 
pathological changes is probably due to the difference in 
trophic relations, possibly to the influence of the spinal 
ganglia themselves. VIII. The fact that the cells of the 
spinal ganglia remain unchanged proves that the trophic 
centres can maintain their own vitality even though the 
fibers which run from them are totally degenerated. IX. 
The pathological changes in the cord are present in the 
motor as well as the sensory centres, which proves that the 
motor cells have less power of resistance than the spinal 
ganglia. X. From the fact that bundles of fibers in the 
posterior columns of the cord having entirely different 
functions degenerate, we may conclude that not only the 
fibers connected with the bodies of Meissner, but other sen- 
sory fibers of the central end of the divided nerves degen- 
erate. (Neurologisches Centralblatt, Nos. 15, 16 and 18, 1892.) 

JOS. KAHN. 



Multiple Tendon and Nerve Suture. — Dr. Lilenthal re- 
ports the case of a boy, 4 years old, who had accidently di- 
vided all the four tendons, also ulnar and median nerves at 
wrist. Twenty-four hours after accident he operated upon 
tendons uniting them by silk sutures. Median nerve sutured 



194 neurological. [December, 

with two lateral silk stitches. Ulnar nerve so small that only 
one suture could be passed and that directly through nerve 
trunk. Wound suppurated, but the nerve sutures all held. 
Later observations showed no sensation over median and 
ulnar distributions, wasting of tissues of hand, and there 
were thenar and hypothenar depressions instead of emi- 
nences. Hand cold, bluish and clammy. Faradization and 
massage employed. Sensation and power of location slowly 
returned and when last seen function was nearly perfect. 
(New York Med. Journal, Nov. 5.) 

B. M. CAPLES. 



Resection of Branches of the Fifth Nerve. — Krause 
exhibited, at the German Surgical Congress, a woman in 
whom he had resected the second branch of the fifth nerve 
within the cranial cavity. The peripheral portions of the 
nerve had been extirpated by Volkmann with temporary 
relief of a neuralgia. A relapse soon occurring, Krause re- 
sected it in the spheno-maxillary fossa, just in front of the 
foramen rotundum, with relief from pain for some time. A 
second return of the pain and the importunities of the 
patient induced Krause to operate again. An incision was 
begun just in front of the tragus, curving backward and 
then forward and downward to the zygoma. Krause com- 
pares the shape of the flap to the outline of the uterus. The 
incision was carried down to the bone at once. The base of 
the flap measured 3.25 cm., its height 6.5 cm., its greatest 
breadth 5.25 cm. This form of incision leaves the tem- 
poral muscle almost intact, the nutrition of the bone is pre- 
served, and the bone at the base is so thin that it is easily 
reflected. The bone was then divided in the line of the in- 
cision and pried back, the part corresponding to the base 
being broken, and the entire mass turned down upon the 
cheek. The opening must be very ample in order to allow 
the brain to be pushed aside. The dura was then carefully 
lifted from the base of the skull by dull spatulas. The 
first point reached in this manner is the foramen spinosum, 
and a branch of the middle meningeal artery. The sep- 
aration must be carefully carried on until the foramen ro- 
tundum and with it the nerve, comes into view. If it is nec- 
essary to seek the ganglion or the third branch the men- 
ingeal artery must be doubly ligated and cut, although the 
third branch is easier to reach in this manner than the sec- 
ond. Hemorrhage is very diffuse and troublesome. As 



1892.] SURGERY AND TRAUMATIC NEUROSES. 195 

soon as the nerve was exposed the author tamponed the 
wound with iodoform gauze and applied a dressing. Five 
days later this was removed, the brain again pushed aside, 
the nerve seized with a sharp hook and about 0.5 cm. ex- 
cised. This was bulbous and redder than usual. A gauze 
drain was inserted through a hole in the bone and the flap 
firmly sutured in place. This was done in February, 1892. 
At the date of report (June 10) no relapse had occurred. 
Union was firm and complete. Krause allows only two in- 
dications for this operation. 1. All other methods, both 
medical and surgical, must have proven futile. 2. The 
symptoms must be severe enough to justify this serious pro- 
ceeding. In resection of the third division of the facial nerve, 
Madeling uses an incision running from the angle of the 
mouth to a point 2 cm. in front of the angle of the jaw. At 
this point the bone is divided. The nerve can be easily ex- 
tracted from the canal. The entire operation can be done 
in 20 minutes. Gussenbauer, in order to reach the nerve 
at the base of the skull, makes a temporary resection of the 
entire zygomatic arch. — (Deut. Med. Wochensch., No. 33, 1892.) 

N 

Q. J. KAUMHEIMEK. 



Division op Superior Maxillary Nerve for Relief of 
Neuralgia. — Dr. Chicken thinks the following important 
in division of nerve: 1. A well-exposed situation for in- 
cision. 2. Non-implication of important structures or or- 
gans, such as orbit or eyeball. 3. Good anatomical land- 
marks. 4. Avoidance of bleeding or oozing. 5. Free 
access to nerve trunk. 6. Practicability of removal close 
to foramen rotundum. 7. The least possible disfigurement 
or loss of function afterward, then limit choice of seat of 
operation either to cheek or zygomatic fossa. An operation 
through the latter fulfills all the conditions. A vertical in- 
cision is made over the base of zygomatic process of malar 
bone about two inches long. Another, parallel to this, over 
the zygoma just in front of temporo-maxillary articulation. 
These are joined about an inch above the zygoma by a hor- 
izontal incision and the flap reflected downward, temporal 
fascia divided along border of zygoma, and bone sawed 
through as close as possible to frontal process of malar an- 
teriorly, and temporo-maxillary articulation posteriorly. 
This fragment is turned down with the attached masseter. 
A director passed under temporal muscle fibers divided 



196 neurological. [December, 

close to coronoid process, belly of muscle turned up with, 
temporal fascia, dissect along posterior surface superior- 
maxillary until prominent spine of corner of pterygoid ridge 
is distinctly felt. Internal to this the superior maxillary 
nerve, running from foramen rotundum to infra-orbital 
foramen, is easily caught on hook ; divide close to foramen 
rotundum, make traction and divide close to infra-orbital 
foramen. Replace parts, insert drainage tube, wire zygoma 
at each end with silver ; replace flap of skin. {Lancet, Oct. 29.) 

B. M. CAPIiES. 



Surgical Treatment of Trigeminal Neuralgia. — At a 
meeting of N. Y. Neurological Society the above subject was 
discussed, which will undoubtedly stimulate physicians tore- 
sort to operative treatment more frequently than at pres- 
ent. The number of cases referred to in the discussion was 
fifteen, in nine of which a thorough exsection of the nerve 
had resulted in radical cure. In six the operation had 
failed to produce relief. A successful issue in sixty per 
cent, of cases of trigeminal neuralgia is certainly a remark- 
able showing as compared with older statistics. (N. Y. Med. 
Jour., Oct. 8.) 



B. M. CAPLES. 



The Technique of Operations for Spina Bifida and 
Encephalocele. — Dr. Carl Bayer, of Prague, gives the re- 
sults of a rather extensive experience in Prag. Med. Wochensch. 
(Nos. 28, 29, 30, 1892.) I. Spina Bifida. In regard to this 
deformity Bayer believes that all cases should be submitted 
to operation. The skin should be incised at the base, leav- 
ing either a cuff or flaps of sufficient size to cover the hiatus 
in the bones. The dissection should be carried down, layer 
by layer, to the meningeal sac. This should be opened and all 
nervous matter dissected from its inner surface and 
replaced in the vertebral canal. If it should prove to be 
impossible to dissect off the nervous layer, the meninges ad- 
hering to it should be resected and replaced with the rem- 
nants of the cord. The greatest care must be given to 
accurate suturing. After the meninges are sutured he 
extends the wound upward and downward and raises the 
skin all around. A semilunar incision is then made on 
each side of the spinal defect, about 2 to 3 cm. from the 
median line through the spinal muscles, of such length 
that the separated portions, when turned on their long axes, 



1892.] SURGERY AND TRAUMATIC NEUROSES. 197 

meet in the median line. There they are sutured, giving a 
firm covering over the spinal fontanelle. The skin is then 
closed over all. He has operated in 13 cases with only 2 
deaths immediately following the operation and attributable 
to it. One case died of an intercurrent affection and four 
others of diverse causes at intervals of from 6 weeks to 2 
years after operation. Six cases are reported in fair health 
from 6 months to 4 years after operation. B.'s conclusions 
are: 1. Operation is imperatively indicated in all cases of 
sacral and lumbo-sacral spina bifida which are born with a 
ruptured sac, in which the sac ruptures inter-partum, or in 
which the nervous matter is exposed, and which show 
neither paralyses nor other serious deformities (clubfoot 
excepted). In these cases all nervous contents of the sac 
must be carefully preserved. 2. The operation should 
also be done in these cases even if they present paralyses, as 
soon as the child is strong and the exposed nervous struc- 
tures are in danger of infection. The usual orthopaedic 
measures must be employed for the paralyses. In these 
cases all the nervous structures are, if possible, to be dis- 
sected off and preserved ; parts strongly adherent, situated 
below the sacral plexus, or visibly degenerated, may be 
removed if the operation is simplified thereby. 3. In cases 
where the sac is covered by normal skin the operation may 
be postponed to a later period. But if the child be other- 
wise healthy it should not be postponed too long, in order 
to obviate the evil result of the unavoidable traumatic 
insults to w T hich the tumor is exposed. If the sac be small, 
it will suffice to unite muscle and skin over the evacuated 
meningeal sac. In larger tumors a resection of the 
meninges can hardly be avoided. 4. Enlarged cranial 
fontanelles are probably present in all cases but furnish no 
positive contra-indication to operation. In pronounced 
hydrocephalus the operation may succeed, but the hydro- 
cephalus may contribute to a fatal result after recovery. 5. 
Having but small experience with spina bifida in other 
sections of the spine, the author is not prepared to give an 
opinion in regard to it. II. Encephalocele. In this deform- 
ity the same rule in regard to incision and suture of sac 
and skin holds good. Ligation en masse or after transfixtion 
should not be done. Asepsis and suturing should be carried 
out with extreme care. Bayer has operated on four cases of 
occipital encephalocele. Case 1 was living 2 years after but 
was somewhat hydrocephalic. Case 3 was alive and healthy 



198 neurological. [December, 

1 year after operation. In case 2 the sac was lined with 
the dilated cerebellum. Death in a week. Case 4, with 
perforated sac, died of meningitis 2 days after operation. In 
conclusion, B. relates a case which presented a tumor as 
large as apple over the anterior fontanelle of a child, 16 
weeks old. After puncture had demonstrated the presence 
of a clear watery fluid Bayer proceeded to operate, believing 
it to be a meningocele in spite of the unusual location. It 
was not connected with the cranial cavity, but proved to be 
a dermoid cyst containing hair, a layer of sebaceous matter, 
and a liquid strongly resembling the cerebro-spinal fluid, 
chemically and physically. Hence the error after aspiration. 

G. J. KAUMHEIMER. 



A New Osteoplastic Operation for Spina Bifida. — 
Prof. Boroff {CM. f. Ghir., No. 22) reports a case of sacral 
meningo-myelocele in which, after excision of the sac, the 
bony defect was closed by a piece of bone chiselled from the 
right iliac crest. At its inner end it was attached to the 
erector spinse which furnished adequate circulation. The 
external surface was turned to the spinal canal, the denuded 
surface outward. In case of a defect higher up a piece of a 
rib might be used to close the gap. ( Wien. Med. Presse, No. 
30, 1892.) 



G. J. KAUMHEIMER. 



Rupture of Middle Meningeal Artery — Successful 
H^mostasis. — The patient was struck by a brick falling 
on his head from the fourth story of a building. On 
admission he presented the following symptoms : irregular 
respiration, unconsciousness, convulsions, a tense pulse at 
fifty-two per minute, and extreme dilatation of the right 
pupil. A wound was seen on the right parietal lobe 
extending to the bone, which was not fissured. The wound 
was extended toward the ear where a fissure was found. 
On removal of part of the skull a mass of blood was found 
between the bone and dura. Active hemorrhage was going 
on. The opening was extended to within a finger's breadth 
of the zygomatic process where a trephine was applied and 
the bleeding vessels found. As ligature was impossible the 
bleeding ends were caught with Pean forceps, which were 
allowed to remain. The coagula were cleared out. This 
was followed by return of consciousness and contraction of 



1892.] SURGERY AND TRAUMATIC NEUROSES. 199 

right pupil. The forceps were removed after two days. An 
attempt to implant a celluloid plate failed. The patient 
has recovered, but complains of headache at the point of 
operation and vertigo. (Berlin. Klin. Wochensch., No. 34, 
1892.) 

G. J. KAUMHE1MEB. 

Spastic Hemiplegia and Epilepsy — Operation. — The 
patient, a girl 15 years old, suffered from left infantile spas- 
tic hemiplegia and hemiathetosis. Since the age of 4 
mouths she was subject to epileptic convulsions. The con- 
tractures and other deformities were improved by operation. 
As the epileptic attacks were cortical in type Sonnenburg 
decided to operate. A temporary craniectomy was made 
over the region of the right central sulcus. A large cyst 
with clear contents was removed. Recovery was prompt. 
The contractures became decidedly less ; the epilepsy, how- 
ever, was as bad as ever. Fifteen months later the same 
piece of bone was again resected and the old cicatrix ex- 
cised. The bone was replaced, but not exactly, in order to 
obviate adhesions or pressure. It united readily. A mod- 
erate improvement in the epilepsy has since taken place. 
(Berlin Klin. Wochenschr., No. 34, 1892.) 

G. J. KAUMHEIMEB. 



Trephine in Epilepsy. — Drs. Maunowry and Camuset 
report (Arch de Neur, July, 1892) a case of longstanding 
traumatic epilepsy in which trephining in the depressed 
fracture was without result. The results were carefully 
tested and the element of error due to the influences of 
acute disorders eliminated. 

J. G. KIERNAN. 

Cortical Epilepsy — Operation. — Dr. Shaw, of St. Louis, 
describes the following case in the Amer. Jour, of Med. 
Sciences for December: Woman, aged thirty-one; multipara. 
Seemed healthy up to time of seizure which occurred with- 
out premonition. While at work had a convulsion; speedily 
became unconscious and remained so for some tiim. 
During six months following had similar attacks about 
every eight weeks ; afterward they became more frequent, 
notwithstanding treatment, until about a year after first at- 
tack, when they occurred every three or four days. Bro- 



200 neurological. [December, 

mides materially lessened number of seizures with loss of 
consciousness but mild attacks of Jacksonian epilepsy con- 
tinued to recur. During first months of disease seizures were 
preceded by sensation of either pricking or numbness, or 
both, beginning in right hand and gradually extending up 
the arm. Frequently this parsesthesia would continue one 
or two minutes before the arm would be convulsed. Some- 
times the brachial spasm would terminate the seizure, but 
more frequently jerking of the arm would be followed by 
forced extension of the toes of right foot and simultaneous 
jerking of the leg. Occasionally the seizures described would 
terminate without loss of consciousness, but often the 
next symptom would be general convulsion with uncon- 
sciousness and conjugate deviation of head and eyes to right. 
During year preceding operation patient had considerable 
pain in right arm and there was right hemiplegia involv- 
ing face, arm and leg. Paralysis was intensified for several 
hours after severe seizures. While sitting or walking pa- 
tient inclined to left. Memory considerably impaired. 
Some evidence of pulmonary phthisis and general nutrition 
below normal. During three weeks preceding operation 
patient had ten convulsions with loss of consciousness and 
twenty of the Jacksonian type. Ophthalmoscopic examina- 
tion showed very marked anaemia of left disc and one 
strangely dilated vein in right retina. Field in both eyes 
concentrically limited. The only diagnosis possible was 
irritating and probably destroying lesion of the arm-centre in the 
left hemisphere. Result of operation: absence of pain, 
parsesthesia or convulsion, mentality improved ; facial de- 
formity less apparent and locomotion easier, but there is ab- 
solute loss of motion in right arm, the motor centre of 
which was the objective point in opening the skull. That 
it was reached is abundantly attested by the result- 
ing condition. Great difficulty was experienced in re- 
moving the button of bone because of a consider- 
able thickening of skull, this being greatest at a 
point exactly opposite that at which the inner table had 
been cut through, and exactly over the arm-centre in the 
ascending frontal convolution. Trephine opening meas- 
ured 1J by 2J inches. Veins over the fissure of Rolando 
were large and full, showing plainly through dura; 
cerebral pulsation quite perceptible. Dura was seen to be 
much darker than normal, cortex was pigmented, and the 
brain bulged into and filled the trephine opening in a pe- 



1892.] SURGERY AND TRAUMATIC NEUROSES. 201 

culiar manner owing to its softened condition. The soft- 
ened area shaded off so gradually into tissue of normal ap- 
pearance that further surgical interference was deemed un- 
advisable. A quantity of sterilized water was made to flow 
on the softened part and it soon became lighter in color and 
more homogeneous in appearance. Wound healed by first 
intention. Dr. Shaw concludes as follows : " According to 
the generally accepted teachings as to the location of the 
cortical area in which are perceived sensations and pain, 
the pain and paresthesia experienced in the paralyzed arm 
in this case should have been taken as an indication of the 
involvement of the cortex between the ascending parietal 
convolution and angular gyrus ; but the fact that the opera- 
tion on the brain, which, as demonstrated by the resulting 
total paralysis of the arm, was made on the arm-centre, re- 
lieving at once and permanently the pain and paresthesia 
without in the least impairing sensation, would tend to 
show that sensory centres exist in the recognized motor area 
as well as in the generally conceded sensory region of the 
brain. The conjugate deviation of the head and eyes in this 
case toward the paralyzed side is in keeping with the fact 
that in cerebral lesions high up, with paralysis on the oppo- 
site side from the lesion, if associated with convulsions, de- 
viation will be toward the convulsed members." As there 
has been no return of symptoms seven months after opera- 
tion, and the arm-centre has not manifested any tendency 
to resume its function, the doctor concludes that there are 
reasonable grounds for expecting permanent arrest of the 
epilepsy. 

Shock contra Shock. — Under this title Prof. M. Benedikt 
describes a very peculiar case. The patient, now sixteen 
years old, dreamt, six years ago, that a dog bit her in the 
left leg. This was followed by spasms which began in the 
left index finger, then extended upward and were succeeded 
by movements of rotation. A fit of weeping closed the 
picture. Since the onset of menstruation the fits had 
occurred almost daily. The last joint of the left index 
finger was spontaneously painful although anaesthetic. 
The left wrist was also painful. She also had monocular 
diplopia in the left eye, rachialgia, tenderness of the nerves 
and inferior cervical ganglion on the left side, constant 
choreic movements in the left arm, and ovarism. Pruritus 
vaginae and petit mal were occasional complications. She 



202 neurological. [December, 

was often able to suppress the spasms by rubbing the anaes- 
thetic finger. Benedikt classifies this as a mixture of hys- 
teria and psychical shock-neurosis. The case is of interest 
as showing how profoundly the unprepared brain can be 
impressed by powerful emotions during natural or hypnotic 
sleep. Benedikt did not believe that there was any organic 
lesion of the cortex and so rejected a craniectomy. After 
all possible means, including magnets, hypnotism and sug- 
gestion had been tried, Prof. Benedikt concluded to try the 
result of a second peripheral shock. With this object in 
view he stretched the radial and median nerves in the 
arm. During the operation it was found that traction on 
the peripheral portions of these nerves had no effect. Trac- 
tion on their central portions promptly caused spasm in the 
muscles supplied by them. Severe respiratory spasm 
occurred in the first twenty-four hours. After that all 
symptoms vanished with the exception of the anaesthesia of 
the last joint of the left index finger. Benedikt has seen 
only three cases of monocular diplopia. He attributes it to 
spasm or paralysis of the ciliary muscle, producing an 
unequal curvature of the lens. All the patients were hys- 
terical. ( Wien. Med. Presse, No. 24, 1892.) 

G. J. KAUMHEIMER. 

Prophylaxis of Surgical Shock. — Dr. J. H. Packard, of 
Philadelphia, writes upon this subject in The Medical 
Standard for December. As rapidity of progress is now 
considered needless, perhaps we have not altogether done 
away with shock from surgical operations in spite of the 
introduction of anaesthetics. The patient, being unconsci- 
ous, makes no complaint of being chilled from exposure, 
but the results are none the less disastrous. When an 
operation can be forseen, the best safeguard against shock is 
the administration of a quarter of a grain of morphine 
hypodermically half an hour before the time. Stimulants 
in moderation may also be given. Only liquid food should 
be allowed on the day of operation and but a small 
quantity of that. The temperament should be considered, 
as the feeble and timid need more decided and vigorous 
stimulation physically, and encouragement mentally, than 
others. Administration of the anaesthetic should be in- 
trusted to experienced persons, and only enough ether given 
to maintain a sufficient degree of unconsciousness. Flushing 
of the wound should be done with hot water onlv and a 



1892.] SURGERY AND TRAUMATIC NEUROSES. 203 

sterilized mackintosh used to prevent wetting of clothing or 
skin. In cases of proposed operation after shock, the effect 
of inhalation of ether affords a tolerably fair test of the 
propriety of operation. 

Traumatic Insanity Cured by Operation. — Dr. Stetter 
(CM. f. Ghir., No. 20) reports the case of a man, aged 28, 
who had sustained a fracture of the skull eleven years 
before. A slight depression occupied the site of the injury. 
He became morose, disinclined to work and irritable. 
In February, 1885, he fell on the back of the head. This 
was followed by weeping, delusions, melancholic depression 
alternating with fits of laughter and of anger. Becoming 
steadily worse, Stetter concluded, in 1887, to operate. The 
depressed bone was situated at the posterior inferior angle 
of the right parietal bone, five cm. behind and at the level 
of the meatus. A flap, including the bone, was raised, 
being 4 cm. long and 2.5 cm. wide. The bone was thick- 
ened and showed an exostosis \ cm. thick at the point of 
greatest depression. This was removed. The dura, which 
was pale, showed a depression as large as a pea. No cyst 
was found. The bone was replaced and united promptly. 
Six months later the patient was completely well. The 
resumption of normal cerebral function required three and 
one-half months. The time which has elapsed between the 
traumatism and the onset of mental symptoms furnishes no 
contra-indication against trephining, although the time of 
recovery varies, of course, with the extent of organic alter- 
ation at the site of injury. ( Wien. Med. Presse, No. 25, 
1892.) 

G. J. KAUMHEIMER. 

I 

Case of Traumatic Paralysis Agitans. — Service of H. 
M. Lyman, M. D., Chicago. Male, aged 37; grocer, but 
formerly a yardmaster. Heredity good, also previous his- 
tory. Has always been temperate in every respect. Five 
years ago, while on a train, was struck upon the back of 
head by an overhanging waterspout. Was temporarily in- 
sensible but worked as usual the next day. No recollection 
of perverted health or abnormal sensations for three months 
following, but about that time noticed progressive weakness 
in right hand and arm, later of the whole right side, and 
subsequently, both sides. After two years tremor was 
noticed, confined to right hand and fore-arm. Special senses 



204 neurological. [December, 

normal, appetite fair and ordinary functions of internal or- 
gans fairly well performed. Characteristic rigidity of spine, 
expressionless countenance, partial flexion of legs, arms, 
fore-arms, fingers and spine. Retropulsion present but no 
aberrations of sensations. Has insomnia caused by numb- 
ness which occurs after lying in one position for a time. 
General muscular weakness. For a period of two years 
was subject to regular attacks of cephalalgia; latterly these 
have disappeared. Patient lias taken thorough courses of 
treatment at Hot Springs and elsewhere which failed to 
palliate, or even relieve his symptoms. Diagnosis — Paralysis 
agitans arising from a sudden and forcible impression upon 
the cerebro-spinal axis at time of accident before mentioned. 
Prognosis — Unfavorable to cure or permanent betterment. 
Treatment — Pil. hyoscyamine crys., gr. 1-200. One twice 
daily. Progress — Treatment with hyoscyamine alone was 
commenced March 31 ; following evening began to note im- 
provement. Two days later, improvement more marked. 
Two days after this, patient walked seven blocks — something 
he had been unable to do before for more than a year. 
Facial stolidity had partially disappeared and there was im- 
provement in attitude. Patient was positive regarding his 
betterment. A week later returned to his home and sub- 
sequent progress not known. {The Chicago Clinical Review, 
October.) 

Laryngeal Symptoms in Traumatic Neurosis. — Dr. 
Benno Holtz has reported two cases, the only ones on 
record. The first was a man, aged 25, who presented other 
symptoms of traumatic neurosis. He was completely 
aphonic and spoke in whispers. The vocal cords seemed 
covered with a dirty layer. During respiration the vocal 
cords were in their normal position but strongly curved 
outward, and showed spasmodic movements during which 
the arytenoid cartilages approached each other. During 
phonation the processes and cartilages approached each 
other, the cords remaining about 2 mm. apart at their 
middle. Application of the constant current caused no 
change. At a subsequent examination, 2 days later, the 
cords were 4 mm. apart. Case 2 was that of a man, aged 47, 
who complained of hoarseness. Examination showed the 
glottis ligamentosa of an elliptical, and the glottis cartilag- 
mosa of a triangular form. The vocal cords were apposed, 
even during the most quiet respiration. At each fourth or 



1892.] SURGERY AND TRAUMATIC NEUROSES. 205 

fifth respiration the cords separated to somewhat more than 
the cadaveric position. This latter movement was variable 
in extent and was frequently accompanied by outward rota- 
tion of one arytenoid cartilage. The patient had, besides, 
motor and sensory paresis of the left side of body and face and 
other symptoms ot traumatic neurosis. Speech was heavy 
and dragging. The author refers the paralysis of motion to 
a disseminated change in the internal capsule, but is unable 
to localize the lesion producing the laryngeal lesion. {Berlin. 
Kim. Wochensch., No. 33, 1892.) 

G. J. KATJMHEIMER. 



A Traumatic Neurosis? — C. M., aged seventeen and one- 
half, fell and injured the ring-finger of the right hand at 
the same time sustaining a severe fright. His work, how- 
ever, was not interrupted. The next day he noticed that 
differences of temperature were not felt on the right side. 
Five weeks later, when first seen, complete analgesia and 
anaesthesia were found on the right side over an area 
bounded by the median line in front and behind, and 
extending from the vertex to a line drawn from the ensi- 
form cartilage to the seventh dorsal vertebra. Tactile and 
thermic anaesthesia and analgesia were absolute in this 
area. Faradic currents which produced tetanic contrac- 
tions of the muscles, were not felt. The motor functions of 
the arm were normal, as were the muscular sense and the 
electric irritability of both muscle and nerves. Patient was 
cheerful and protested that his trouble was too trivial to 
need treatment. As disease of the peripheral nerves as well 
as a disease of the cord, such as syringomyelia or haema- 
tomyelia, could be excluded, the author attributes the symp- 
toms to a functional disturbance of a very limited part of 
the psycho-sensory sphere, a traumatic neurosis in the 
literal meaning of the phrase. Treatment by means of the 
faradic brush was followed by recovery in 6 weeks. (N. 
Coester, Berlin. Klin. Wochensch., No. 31, 1892.) 



G. J. KATJMHEIMER. 



Fatal Inhibition Phenomena of Uterine Inception. — 
It is well known (Prog. Med., Oct. 15, 1892) that a slight sud- 
den blow on the abdomen of a frog will produce a state of 
seeming death in that animal. This inhibition phenom- 
enon is not, as Brown-Sequard has shown, limited to the 



206 psychological. [December, 

splanchnic viscera ; the larynx and uterus may present it. 
Obstetricians and gynaecologists have had the misfortune to 
recognize it during curettage, during an injection, or even 
during simple exploration of the uterine cavity. Death in 
this case, according to Bonvalot ( These de Paris, 1892), is an 
inhibition phenomenon due to rapid arrest of the heart and 
respiration. This is sufficiently well established for experts 
to take it into account in deaths during delivery or gynae- 
cological operations. 

J. G. KIKBNAN. 



PSYCHOLOGICAL 



PATHOLOGY AND SYMPTOMATOLOGY. 

A Study of the Sensory and Sensory-Motor Disturb- 
ances Associated with Insanity, from a Biological and 
Physiological Standpoint. — Dr. H. A. Tomlinson consid- 
ers that the theory of evolution furnishes a working hypoth- 
esis by means of which many facts of insanity are ex- 
plained. The asylum physician sees more clearly the in- 
fluence of environment and association independently of 
morbid conditions, than does the physician in general neu- 
rological practice. The mind is not an entity, therefore its 
disturbances are due to the same causes which produce dis- 
turbances in the general nervous system. The primary 
difference between sensory and motor disturbances occur- 
ring in insanity and general nervous disease, is the marked 
tendency to variation in the former, even where the sensory 
manifestations and disturbance of motility are as apparently 
persistent as in gross lesions of the brain and cord. The 
pathological history of insanity is vague, and from an an- 
atomical standpoint furnishes little information. In the 
majority of cases of insanity furnishing material for post- 
mortem study, the general degenerative changes have ob- 
scured any definite pre-existing lesion. Even where lesions 
are found, the history of the case will often show that they 
have been engrafted upon pre-existing insanity. In cases 
where insanity has followed gross lesion of the brain the 
perversions are in no wise different from those where no 
such lesion exists. A study of a single nerve cell with ref- 
erence to progress of degeneration, will enable us to obtain a 
clearer idea of general conditions present than an anatom- 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 207 

ical study of the brain substance. If we assume that the 
nervous mechanism in the foetus is endowed with a definite 
potentiality, then, in the progress of development, the en- 
vironment and experiences of the individual governed by 
the laws of organic development would affect this potential- 
ity, relatively and generally. In a normal nervous system 
this potentiality would be equal in all its parts, but if, as is 
usually the case, the individual has some imperfection of 
development, some parts of the mechanism will be in a con- 
dition to succumb to a smaller strain than others. The de- 
gree of disturbance will depend upon the amount of im- 
perfection, and the character, by the environment of the in- 
dividual. All of the sensory and motor symptoms pro- 
duced permanently by pressure or gross lesion of brain or 
cord, are produced temporarily by cell irritation or exhaus- 
tion occurring during a course of chronic meningitis, scle- 
rosis or atrophy. The doctor describes three cases illustrat- 
ing his theory, the first of syphilitic brain disease, the sec- 
ond a case of general paralysis — these two showing motor 
degeneration — and the third,one of intellectual degeneration. 
If the doctor's hypothesis be tenable the deduction follows, 
that the cerebral cortex is the originator of all the activities 
of the organism, and that those manifested automatically by 
the spinal centres, which we find in the reflex mechanism, 
are the result of the division of labor caused by evolution, 
and represent the development from the simple and lowly 
organized to the complex. These activities become more 
uniform and persistent until, without the intervention of 
active consciousness, they respond definitely to external im- 
pressions. It follows, then, that any breach in the integrity 
of the cortical function would produce disturbance of the 
uniformity and definiteness of its activities, while the reflex 
mechanism, subject to the same source of disturbance, would 
react irregularly, giving rise to centrifugally excited 
activities without correspondence to the external stimuli. 
The sensory and motor disturbances associated with insanity 
may be arranged as follows : Sensory. Disturbance of 
general sensation including anaesthesia, analgesia, paresthe- 
sia and disturbed muscular sense; disturbances of special 
senses, such as illusions and visceral hallucinations. Motor. 
Tremor, local or general, automatic associated movements ; 
paresis and paralysis involving general muscular function ; 
vaso-motor disturbance, spasm, and convulsion. Analysis 
of these different forms of disturbed functional activity 



208 psychological. [December, 

seems to lead to the conclusion that even in their most 
complex manifestations they are simply the outcome of 
increased or decreased irritability in the functional nerve 
cell, their complexity depending upon the number of func- 
tional groups associated, while they are manifested in their 
simplest form by the general involvement of the cerebro- 
spinal mass. The forms of insanity with which the various 
sensory and motor disturbances are associated, further con- 
firm the generalization as stated. In exaltation all forms of 
sensory and motor activity are present in excess. In acute 
mania the first manifestations are self-absorption and 
irritability, for external impressions are not fully recognized 
and the resulting discharges of energy are imperfectly co- 
ordinated. Dr. Tomlinson concludes his article as follows : 
" I will venture the opinion that it is in the direction which 
the theory of evolution leads that we must look for future 
progress in the study of insanity and its associated disturb- 
ances, especially when its prevention and cure are the 
objects sought, and we must look to biology and physiology 
rather than to pathology, for our guide in these studies." 
{Jour, of Nervous and Mental Diseases, Oct., 1892.) 



" Spells". R. M. Phelps, M. D., says that in ordinary phys- 
ical ailments " spells " are not seen, and our philosophy is 
inadequate to give good reason for them in insanity. The 
periodicity referred to is entirely outside of any irritation 
from surroundings or secondary disease. These periodical 
changes in behavior are so variable as regards times, seasons 
or even regularity, as to make clear definition almost im- 
possible, and the author objects to placing them in a dis- 
tinct class in any classification. Spitzka ranks " periodical 
insanity", as he calls it, with paranoia and imbecility, and 
assigns it a degenerative tendency. Clouston finds the 
periodic tendency to be an almost universal characteristic of 
mental diseases, and finds it more marked when the disease 
is hereditary, and also more common in pubescent cases. 
Tuke says that " periodicity " is more marked in mental 
depression than in exaltation. Folsom, KrafFt-Ebing and 
Bevan Lewis give heredity as a strong cause. There is 
doubtfully shown a greater tendency towards periodicity 
among the female population : this seems to be true after 
setting aside the cases of menstrual origin. From Dr. Phelps' 
experience he furnishes the following classification : " 1st. 
The class of cases that have menstruation as exciting cause 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 209 

seems to be the most obtrusive and prominent. 2nd. The 
class of cases with regular exacerbations is the largest, but a 
large proportion of the cases are ill-defined. 3rd. The 
class of ' recurrent' cases which have exhibited a cyclical 
tendency is rather small. 4th. ' Circular insanity ' is only 
the most perfect form of the same cyclical tendency and is 
very rare if confined to typical cases. 5th. In all the four 
classes there is reproduced, almost invariably, the same 
character of behavior at each cycle, while in contra-distinc- 
tion no two separate cases at all closely resemble each other. 
6th. Almost all the cases begin in the early period of life. 
This is as significant an element as any to be mentioned. 
It fits into the statement that periodicity and essentially 
degenerative tendencies go with pubescent cases. 7th. The 
cycles are so irregular as to time as to strongly tend to pre- 
clude their coincidence with any healthy physiological 
cycles. 8th. Although these cycles are almost sure to return 
one cannot predict the exact time in any case I have met ; I 
always have to say, 'about such time'. Subordinate to 
this is the fact that cases can seemingly skip the turn of one 
cycle, or at least have symptoms so mild as to be hardly 
noticed." These observations are from 3,000 cases. In 
closing, Dr. Phelps notes the suggestive studies of Laycock 
and Smith. The former laid down the statement that there 
is a " general law of periodicity which regulates all of the 
vital movements of all animals". He also laid down the 
fundamental unit of change to seven days of twelve hours 
each and its multiples. A consideration of the critical days 
in fever and other diseases seem to form most of his data. 
Smith examines the changes actually undergone by himself 
and others. He found a distinct daily cycle, an obscure 
weekly cycle, and a distinct annual cycle. Dr. Phelps' con- 
clusion is a somewhat negative one, viz.: that the variations 
are so irregular that he would form no theory to account 
for them, but would simply note their most frequent occur- 
rence in cases which would be styled " pubescent," that is, 
"those cases having their origin in the developmental period, 
having strong hereditary taint and, essentially, chronic 
degenerative character." (Hospt. Bulletin of the Second Minn. 
Hospt.for Insane, November.) 



Primary Confusional Insanity. — Dr. Chaslin concludes 
{Ann. Medico- Psych., Sept.-Oct., 1892) that there exists a type 
of acute mental disease which is neither mania nor melan- 



210 psychological. [December, 

cholia, which should be attributed to rapid and brusque 
exhaustion of the central nervous system (very frequently, 
according to the most recent authors, consecutive to infec- 
tion or auto-intoxication) and which should be separated 
from what is designated " degeneracy ". It is a psychosis 
intermediate between the " pure " psychoses (of Spitzka) and 
the insanities with accentuated, profound lesions. It 
assumes often the type of a true somatic disease with 
denutrition, fever, etc., that accompany it. From a psychic- 
al point of view it is essentially characterized by confusion 
of ideas as a sequence of enfeeblement of inco-ordination of 
ideas, perception and personal apperception. It may, or 
may not be hallucinatory. It may be accompanied with 
motor agitation, depression or stupor. The emotional 
state, often indifferent, may present brusque variations. The 
psychosis has the greatest possible analogy with psychic 
symptoms due to chronic intoxications. The psychosis, in 
Dr. Chaslin's opinion, merits the title of mental confusion, 
under which it has been described in France, adding the 
term, primitive, to distinguish it from the secondary states in 
which confusion exists. It is obvious that Dr. Chaslin has 
included under this term not only the " Verwirrheit " of the 
German and the primary confusional insanity of Spitzka, 
but also mixed cases where an emotional tinge (absent in 
the pure psychosis) exists. 

J. G. KIERNAN. 



Abulia with Interrogations and Movement Disorder. — 
Drs. T. Raymond and T. Amaud {Ann. Medico-Psych., Sept. 
-Oct., 1892) point out that under this title may be 
included certain psychical symptoms which cannot be 
included under "folie du doute avec delire du toucher". 
The general state is constituted by emotivity, psychomotor 
hesitation and neurasthenia. The patients, as a rule, betray 
lack of logical balance and default in neuro-functional 
stability. This primitive and general trouble which in- 
volves the motor elements common to the intelligence and 
the will, determines in each of the mental operations symp- 
toms of the same order; intellectual hesitation producing 
doubt and necessity for internal repetition and strange 
affirmations — abulia with all its consequences — hesitation, 
and further difficulty of muscular movements and acts 
which cannot be executed with normal procedures but 
require accessory assistance. Beneath the general state 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 211 

which is pretty nearly fixed and constant, appear exceed- 
ingly variable symptoms which are but exaggerations of 
psychomotor instability obsessions, fixed ideas and bizarre 
acts (hand washing, fear of contact, repetitions, etc.). Such 
symptoms vary with, and in the patient, in the faculty of 
perception ; in its mode, which has been denominated static 
and passive, the intelligence is not sensibly altered. The 
patient preserves consciousness of his state, which im- 
plies a rectitude of judgment. Intelligence is altered in its 
power of co-ordination and of fixation of ideas ; that is, in its 
active mode, especially in what is peculiar to its active mode, 
voluntary attention. The will is incontestably the most 
affected and in its double action. As an impulsive it is so 
affected as to produce perpetual irresolution, hesitation 
and uncertainty of movement. As an inhibitory power the 
affection of the will is shown in imperative conceptions and 
impulses. The patients are not masters of certain of their 
ideas which are imposed on them in spite of themselves. 
Automatism replaces will. The patients become, according 
to Billod, " idiots of the will ". 

J. G»KIKRNAN. 

Psychic Stigmata of Degeneracy. — Dr. Catsaras, of 
Athens, Greece, concludes (Ami. Medico- Psych., Nov.-Dec, 
1892) that conscious imperative hallucinations should 
occupy a place among the psychic stigmata of degeneracy. 
These may occur under two aspects isolated or com- 
bined. Among the combined Dr. Catsaras has observed : 
A; visual auditory and verbal psychomotor (conscious 
uncontrollable dialogues with vision of absent person) : 
B ; verbal auditory and verbal psychomotor (as before but 
without vision) : C ; visual and auditory but non-verbal 
hallucinations (sights and sounds without enforced conver- 
sation). There is a category of episodiacal symptoms which 
deserve designation as conscious auto-suggestions in the 
waking state. These symptoms merit classification as 
psychic stigmata of mental degeneracy. These have the 
same basis as other psychic stigmata, default of equilibrium 
from which results conscious, but uncontrollable action of 
one or more cerebral centres. The prognosis of these is 
graver than that of imperative conceptions. 



J. G. KIERNAN. 



Criminal Man does not, according to Houze and Warnotz, 
constitute (Revue Intem't. de Biblio Med., Oct. 10, 1892) a 



212 psychological. [December,. 

peculiar species. The type designated by Lombroso 
"criminal man" is an hybrid product of several conditions, 
not a real type. These conditions are realized but in a 
minor proportion of criminals. Some criminals belong to 
the degenerate type but do not constitute a special variety. 

J. G. KIERNAN,. 

Minor Psychical Disturbances in Women. — Dr. Camp- 
bell says that women under all conditions tending to upset 
the general health are very liable to psychical disturb- 
ances. Let any woman, no matter how sane, be housed and 
fed like the average woman of the " slums ", and she will 
manifest at some time or other certain symptoms, they being, of 
course, prone to thrive best during pregnancy, when weakened 
by nursing, at climacteric or menstrual derangement. Cases 
displaying these symptoms come to the London hospitals 
by the thousands, and are interesting as marking the 
borderland between sanity and insanity. These observa- 
tions were based on 200 cases, none of which went on to 
insanity. These cases merged imperceptibly into "melan- 
cholia witHout illusion" in which the patient usually felt 
quite well in the evening, the influence of surroundings 
being marked. Irritability generally present. Hypersesthesia 
of all special senses, impressions on sensory nerves and organs 
provoking sensations which were actually and unpleasantly 
felt. Intolerance of noises. Emotional irritability. Fear and 
anger readily excited. He thinks it not strange that these two 
emotions, both primitive, should attain prominence in slight 
mental dissolution. Suicidal impulse common. Recent 
investigations on ptomaines, leucomaines and uric acid made 
it equally certain that it might also result from the opera- 
tion of poisoned plasma — for on the substitution of normal 
plasma for abnormal the symptoms vanished as if by 
magic — at same time remembering that molecular structure 
of nervous tissue might be so affected by the prolonged 
action of the poison, though the condition of plasma might 
be rectified at once, that some time might elapse before the 
nervous tissue could recover itself. (British Med. Jour., Aug. 

^0. ) B. M. CAPLES. 

Criminal Imperative Conceptions. — Dr. Magnan (Progres 
Med., August 13, 1892) in a paper read before the Congress 
on Criminal Anthropology, states that in otherwise normal 
conditions the imperative conception is ordinarily transitory 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 213 

and easily repressed. The intellect is not involved otherwise, 
and the superior centres do not lose their control over the 
psycho-motor centres. In consequence, the imperative con- 
ception does not become an imperative impulse. In morbid 
states the conception is tenacious and tyrannizing and 
accompanied with a moral pain which subjugates the will. 
For such states the conception leads to the impulse and the 
conscious subject is impelled to an act which he abhors. 
In some instances the discharge of a motor centre, as in 
onomatomania, is so abrupt that there is no time to resist 
the impulse. Often in criminal imperative conceptions the 
victim resists by himself; sometimes friendly counsel proves 
effectual. At other times a long struggle results in the tri- 
umph of the impulse. 

J. G. KIERNAN. 

Homicidal Imperative Conceptions. — Ladame (Ibid) 
took Westphal's view of the imperative conception which 
occurred on an otherwise intact intelligence whose morbid 
value was fully recognized by the patient, but of which he 
could rid himself. The homicidal impulse may belong to 
the same category of the degenerate as the kleptomaniacal 
and dipsomaniacal types, and was often periodic or recurrent 
in character. It frequently remained theoretic and did not 
become an act. It might be episodiacal also and result in 
•epidemic form after great crimes. Dr. Gamier, in discussing 
Ladame's paper, said that perusal of sensational descriptions 
of murder might in predisposed persons awaken these con- 
ceptions, " some one has committed a crime, I may also", 
and the fear of the possibility thus expressed awaken a 
tendency to the act. 

J. G. KIERNAN. 

Consciousness in Epilepsy. — Dr. Gamier (Prog Med., 
August 13, 1892) says that the states of uncertainty 
-accompanying imperative conceptions while vertiginous 
and coincident with loss of equilibrium, are distinguished 
from epilepsy by the unconsciousness and amnesia of the 
latter. Benedikt, in replying to Gamier, claimed that cer- 
tain epileptics may be conscious of the acts they commit, at 
least partially, so far as the onset and termination of the 
act is concerned. He had observed the case of an epileptic 
homicide who retained remembrance of the homicide in 
detail but ascribed it to another. It was a species of hal- 
lucinatory dream. 

J. G. KIERNAN. 



214 psychological. [December, 

Systematized Negative Delusions of progressive evolu- 
tion, are, according to Dr. F. L. Arnaud (Ann. Medico-Psych., 
Nov.-Dec., 1892), most frequent in females. They show 
themselves only after 55. In many cases they appear 
after one or more attacks of ordinary melancholia. In 
typical cases they develop only after a more or less pro- 
longed period of agitated melancholia. The psychosis 
characterized by these symptoms may be regarded as a late 
psychosis arising on a basis of intermittent vesanias. It has 
a grave prognosis. 

J. G. KIEUNAN. 



A New Form of Visual Hallucination. — Pieraccini 
(Rivista Sperimentale, XVIII, II, Aug., 1892) describes the case 
of an insane man of the criminal type, in whom occurred 
visual hallucinations which could be made to disappear by 
closing either eye indifferently. The hallucination could 
not, therefore, be regarded as a unilateral one, and he 
endeavors to account for its peculiarities on the basis of an 
auto-suggestion, as the subject was an impressionable one. The 
closing of one eye produced a belief that he could not see 
without it and induced a sort of psychic blindness to the 
hallucinatory image. On another occasion, when the same 
patient was storming against a persecutor, whom he said 
was tormenting him from a hole in the ceiling, the 
attendant promised to go above and prevent further trouble, 
and on his pretending to do so the hallucination ceased 
entirely, to the great satisfaction of the patient. 



H. M. BANNISTER. 



Collective Suggested Hallucinations. — Dr. E. Laurent 
states (Revue de V Hypnotism, August, 1892) that under the 
influence of a pre-occupying thought feeble minds may 
create hallucinations by auto-suggestion, and, if they be in 
contact with persons easily affected by suggestion, they may 
communicate to them their hallucinations. A superstitious 
peasant believed he heard behind him a noise which fol- 
lowed him home. Arrived there, he spoke of it to his wife. 
Later he heard it under his bed and it was also heard by 
her. Two narrow-minded, very religious girls, were sent 
into a field by their father in lieu of attending a procession 
in their village. In the middle of their work one of them 
had an hallucination of a splendid procession and showed 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 215 

it to her sister. The two then called a friend who also saw 
it. The arrival of a sceptic caused the hallucination to 
vanish. It was described by all three in similar terms but 
with some variations. The number of priests in it varied. 

J. G. KIERNAN. 



Hysterical Mutism. — Apsithyry is a term applied to this 
condition by Solis-Cohen (Annal des Mai. de l' Oreille, du 
Larynx, etc., July, 1892). The condition is essentially a 
central one as the larynx is normal. Careful examination 
will be required to eliminate simulation. Cure is as rapid as 
the onset of the disorder, and better results are obtainable 
from psychical influences than from therapeusis. The con- 
dition has a certain analogy to the laryngeal crises of tabes 
and the condition sometimes found in normal persons sub- 
mitted to sudden moral shock. In these last cases the 
apsithyry is transitory. 



J. G. KIERNAN. 



Hysterical Amnesia, according to Charcot (Arch, de Neur. 
July, 1892), is characterized, not by a total destruction of 
elementary psychological phenomena, but by an impotence 
of centralizing power. There is always an egotistic 
personality which is incapable of attaching events. Con- 
ceptions are sometimes capriciously neglected, whence 
vague and continual amnesias result. Sometimes de- 
terminate images having defined characters are neglected, 
whence curiouslv localized amnesias result. The causes 
which determine these particular localizations of amnesia 
may be found in the anaesthesias which coincidently occur, 
or in variations of conscious sensibility. 

J. G. KIERNAN. 



Psychic Symptoms of Basedow's Disease. — Basedow's 
disease is often accompanied by psychic symptoms which 
are accounted by some authorities as symptoms of the dis- 
order itself, and by others as merely superadded phenomena. 
Serieux and Raymond conclude (Revue Intern't. de Biblio. 
M&d., September 10, 1892) after an extended study of the 
mental disturbances occurring in exophthalmatic goitre, that 
the phychic troubles of Basedow's disease are not an integral 
part of the disorder. They have no special characteristics 
and assume almost all psychical types. Some appertain to 



216 psychological. [December, 

the neurasthenic type, or to the hysteric, epileptic, 
hallucinatory, confusional, maniacal or melancholiac 
type. One group belongs to the degenerative type and 
has the usual psychic and somatic stigmata. The asso- 
ciation of this with Basedow's disease is due to the 
hereditary taint underlying both. This taint may show 
itself in the explosion of a delirium during the progress of 
Basedow's disease, during its progress, or even after recovery 
from it. The moral shock producing Basedow's disease may 
be revealed in the delirious conceptions. Exophthalmic 
goitre may, in predisposed subjects, act like any other excit- 
ing cause. Basedow's disease is a bulbo-protuberantial dis- 
ease due to exaggeration of physiological functions. Emo- 
tionalism underlies the disorder and results from desequili- 
bration of the vaso-motor centres, similar to that occurring 
in other cerebral or spinal spheres in the degenerate. 

J. G. KIERNAN. 

Syphilitic Insanity. — Dr. Newth writes an article in 
which he states that the study of cerebral syphilis is one of 
interest and importance; of interest because of its many 
curious symptoms, and importance, for if diagnosed correctly 
in its early stages it is then fairly curable, or at least the 
progress of the disease may be checked for a considerable 
time by appropriate treatment. There is a very close 
resemblance between general paralysis of the insane and 
syphilitic insanity, and one is often mistaken for the other. 
Syphilis of brain and nervous system is very variable in 
its development and characteristics, the nervous system not 
corresponding with any special lesions of brain or spinal 
cord. A sudden and severe attack of nervous symtoms in 
in a person previously apparently healthy, affords a strong 
presumption that these symptoms are due to syphilis. The 
erratic character of symptoms and their abrupt develop- 
ment are two of the most characteristic features in syphilitic 
insanity. Patient may show signs of syphilis as indented 
teeth, effusion of lymph and formation of vascular nodules 
in iris, perforation of palate, copper-colored eruption nodes 
on long bones, syphilitic ulcers on leg, signs of buboes, 
chancres, etc., irregular patches of baldness, linear scars 
running outward from corners of mouth, broad sunken 
nose, instability of character, fits of unreasonable passion, 
defective memory, errors in speaking or writing, that is, 
using wrong words to express meaning, omitting letters 



1892."] PATHOLOGY AND SYMPTOMATOLOGY. 217 

or words in writing, and lack of faculty for business. One 
suffering from syphilitic insanity has a peculiar imbecile 
expression, his appearance is flabby, flaccid, vacant. Notices 
nothing attentively, slouching manner in walking, gait 
uncertain, stumbling or staggering with tendency to fall. 
Generally complains of vertigo or giddiness, may have 
slight apoplectic seizures, sometimes accompanied by hemi- 
plegia, followed by epileptic or semi-epileptic state — these 
latter may be the first expression of the disease — partial or 
complete paralysis of extremities not uncommon. These 
paralyses do not seem to coincide with any special cerebral 
lesion. May be facial paralysis on one side and oculo- 
motor on the other. Aphasia may be coincident with left 
hemiplegia; may closely resemble hysteria. Locomotor 
ataxia not an uncommon result of syphilis, but is liable to 
remissions. There is loss of memory for recent events, lack 
of aesthetic feeling, and the ethical or moral sentiments are 
wanting in expression, syphilitic patients being often 
most obscene in their behavior and regardless of the 
decencies of life. Intellectual faculties dormant, innate or 
cognate, ideational faculties torpid. If there is furious 
mania it is the mania of impotence. The want of coinci- 
dence characterizes syphilitic disease of the brain. Delu- 
sional insanity may be due to syphilis ; these patients are 
very suspicious, and acting upon these delusions become very 
dangerous. Anti-syphilitic remedies, if early and judiciously 
administered, do great good, such as mercury, iodides andi 
arsenic. {Lancet, October 15.) 

B. M. CAPLBS.. 



Kleptomania and Pregnancy. — Dr. Lefebure, of Brussels, 
has observed {Prog. Med., Aug. 13, 1892) the case of a 
woman without known hereditary taint, who was klepto- 
maniacal with each pregnancy and at no other time. 



J. G. KIERNAN. 



Puerperal Insanity in the First, and Temporary 
Glycosuria in the Second Confinement. — Max Flesch re- 
ports the following case : A woman with neurotic inherit- 
ance had a convulsion after labor, possibly due to excite- 
ment and worry, followed by melancholia which ended in 
recovery. Following her second confinement there were no 
symptoms directly traceable to the nervous system, but she 



218 psychological. [December, 

had a temporary glycosuria, which, under a properly regu- 
lated diet, disappeared in about eight days. The author 
considers this glycosuria a neurosis. — (Berl. Klin. Y/ochensch. t 
Oct. 24, 1892.) 

JOS. KAHN. 

Acute Alcoholic Insanity. — Knorr reports a series of 
cases of acute alcoholic insanity. The patients were all 
habitual drinkers who, shortly before the onset of the 
disease drank to great excess. The symptoms were those 
of an acute paranoia with primary hallucinations of hearing 
followed by delusions of persecution, without delusions of 
grandeur. The course of the disease was rapid, always end- 
ing in recovery, thus differing from ordinary paranoia in 
which the prognosis is unfavorable. Delirium tremens is a 
condition of exhaustion of the brain, while acute alcoholic 
paranoia is a psychosis occurring at the height of the 
alcoholic intoxication. In the former there are hallucina- 
tions of all the senses, more particularly that of sight, while 
in the latter there are simply hallucinations of hearing, 
otherwise the mind is clear. (Allgemeine Zeitschrift fur 
Psychiatrie, Vol. 48, No. 6.) 

JOS. KAHN. 



Mental Disorders from Exophthalmic Goitre. — Dr. 
Jacquin reports (Revue Intrn't. de Biblio. Med., Oct. 25, 1892) 
the case of a 64-year-old woman whose father and sister 
were insane, who had had four attacks of melancholia, exoph- 
thalmic goitre appearing during the fourth attack. Dr. 
Jacquin, while admitting an hereditary influence in this 
case, points out that exophthalmic goitre may produce 
mental symptoms by the epileptiform attacks occasioned by 
it, as well as by the denutrition it provokes. In certain pre- 
disposed cases the relationship of the nervous phenomena 
can be followed from childhood until the onset of insanity. 
In others, insanity and the goitre occur together. Exoph- 
thalmic goitre can produce, both in predisposed and non- 
predisposed individuals, mental disorders having a peculiar 
type, as well as ordinary types of the psychoses. These last 
are, however, apt to be tinged by goitric mental symptoms. 

J. G. KIERNAN. 

Variola and Insanity. — Deugler (Rev. Med. d6 VEst., July 
15, 1892) has observed a variola epidemic in the Marville 
(France) insane-hospital. Six insane patients were attacked, 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 219 

one of whom died. Deugler finds that variola exerts but 
little, if any, influence on chronic psychoses. It has a 
temporarily beneficial influence on acute psychosis. Vac- 
cination is less successful with the insane than the sane 
because of the lack of care of the former. Vaccination was 
without effect on the mental state. 

J. G. KIERNAN. 

Cholera and the Psychoses. — Dr. Camuset states (Ann. 
Medico-Psych., Nov.-Dec, 1892) that after the reaction from 
the alleged period of cholera a fugacious febrile delirium 
sometimes results. The choleraic attack sometimes checks 
hysterical symptoms of subjects in whom they have been 
present at the time of the onset of the cholera. The 
choleraic attack during its grave periods checks maniacal 
states whatever their nature or duration. After recovery, 
however, these states, as a rule, return. Choleraic attacks 
temporarily ameliorate melancholia, but such amelioration 
is not very frequent. Systematized delusions, in Dr. 
Camuset's experience, were not affected by cholera. The 
dements and idiots recognized the gravity of the disease 
with which they were attacked. Secondary confusional 
lunatics regained during the choleraic attack a surprising 
degree of mental lucidity. 

J. G. KIERNAN. 



Hepatic Insufficiency and the Psychoses. — Dr. Klippel 
has recently discussed (Arch. Gen. de Medicine, Aug., 1892) 
the role of the liver in the aetiology of the psychoses. A 
very general belief exists in the serological r6le of the 
auto-intoxications in the psychoses. Alienists have des- 
cribed a nephritic psychosis due to uraemia. Klippel claims 
that hepatic disorders should be taken into serious consider- 
ation, since, though these have been believed to exert but a 
doubtful influence on psychoses, the hepatic lesion assumes 
a decidedly obvious psychic importance. Not only* is it 
capable of keeping up and exaggerating a psychosis, but it 
may be the cause thereof. In order that the action of the 
liver in the psychosis should be clearly analyzed it is 
necessary that an analysis be made of the functional state of 
this organ. Klippel has, therefore, not only examined the 
usual symptoms of hepatic disease (icterus, ascites, etc.) 
which may show themselves long ere the hepatic cell is 
exhausted, and are often wanting even though this cell be 
profoundly altered when the veins and hepatic ducts re- 



220 psychological. [December, 

main normal, but has recognized hepatic insufficiency by 
aid of physiological signs which are not affected by the 
elements of error just described, and which appear when- 
ever the hepatic cells are affected. The evidence of experi- 
mental glycosuria, the presence of certain hepatic coloring 
matters in the blood, the decrease of urea, the increase of 
uric acid, the state of the faeces, and urobilinuria, enable this 
state of things to be recognized. This last sign, in particular, 
has been to Klippel of great value, and he has chosen it as 
giving in some respects an exact measure of the functional 
state of the hepatic cell. Without neglecting other investi- 
gation procedures which serve as central experiments, 
Klippel uses urobilinuric examination to determine the 
state of the liver. The spectroscopic results of urobilinuria 
are adapted both for qualitative and quantitative results. 
The characteristic ray will, to a pretty exact degree, measure 
by its intensity the amount, and Klippel has found by this in- 
genious procedure that urobilinuric variation corresponds to 
psychical variation, and that urobilinuria discharge coincides 
with modification of the mental state. In consequence, this 
symptom shows, from the hepatic pathogenic point of view, 
the influence of the liver upon the psychoses, and indicates, 
moreover, the necessity for treatment of hepatic insufficiency. 
Klippel is of opinion that urobilin indicates a lesion of the 
hepatic cell which may be either the product or the cause of 
a psychosis. He is of opinion that the action of alcohol upon 
the liver is a potent factor in producing the psychic symp- 
toms of alcohol; in certain cases alcohol may act directly upon 
the brain but also indirectly through the effects produced 
by its influence upon the liver and kidneys. In some cases 
the hepatic disorder is a primary cause without which the 
psychosis would not exist. Klippel cites the following case 
of this nature which he denominates hepatic insanity. 
A 62-year-old man, who was of excellent hereditary 
antecedents so far as known, and never was an alcoholist, 
had no gastric embarrassment nor fever but presented 
hepatic insufficiency characterized by all the symptoms 
cited, and in particular by urobilinuria. This patient, after 
a maniacal explosion with grandiose delusions, became 
depressed and died in coma. At the acme of the depression 
there was decidedly decreased urobilinuria. On autopsy 
no well marked cerebral lesions were found. The majority 
of the other organs were almost equally healthy. There 
was, however, granular atrophic degeneracy of the liver 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 221 

characterized by lobular anaemia, irregularity of the trabec- 
ule, and very pronounced atrophy of the cells, the greater 
number of which were transformed into granular bodies 
without nuclei. The term, acute delirium (delire aigue, 
delirium grave of Spitzka, typhomania) might be justifiably 
employed as symptom designation of this case, but there 
was notably absence of pyrexia. Alcoholism and paretic 
dementia could be rejected in the diagnosis. The first, 
because of the absence of alcoholic antecedents ; the second, 
because of the characteristic lesions. The hepatic condition 
sufficed to explain the symptoms. Similar psychic phenom- 
ena have resulted in cases of hepatic disease of determin- 
able aetiology, hence Klippel believes hepatic insanity 
should take its place in nosology with nephritic insanity. 

J. G. KIERNAN. 



Uric Acid in Conditions of Mental Depression. — Mar- 
zocchi (Rev. Sperimentale, XVIII, August, 1892) publishes a 
series of observations made by him upon seven patients, as to 
the proportions of uric acid and urea in various stages of 
mental depression. The instigation to these observations 
came from the publication of Haig (Brain, 1891) and the 
earlier statements of Maudsley (Phys. and Path, of the Mind) 
as to the auto-intoxication from u±'ic acid. Marzocchi's 
conclusions are stated as follows : (1). Absolute and rela- 
tive increase of the uric acid in the blood occurs in certain 
forms of melancholia. (2). It is not probable that this 
increase is merely an effect of the morbid process, taking 
into consideration the psychic depressive action of uric acid. 
(3). While it is not justifiable to attribute to the uric acid 
the importance of a cause, it may be credited with produc- 
ing an aggravation of the morbid condition. 

H. M. BANNISTER. 



Treatment of the Insane by the Subcutaneous Injec- 
tion of Infusion of Nervous Tissue. — Culere placed a 
portion of the grey matter of the brain of the sheep in 
double its weight of glycerine and allowed it to macerate for 
twenty-four hours. He added an equal quantity of boiled 
water and filtered. Four grains of the clear filtrate were 
injected subcutaneously in the loins every second day, with- 
out bad results in five hundred injections. The treatment 
was employed in fourteen cases and while the mental condi- 



222 psychological. [December, 

tion did not improve, there was a marked change for the 
better in the physical condition. The appetite increased 
and the patients gained in weight and strength. ( Wiener 
Med. Presse, No. 41, 1892.) 

JOS. KAHN. 



Phthisis Among the Insane ; by S. Linton Phelps, M. D. — 
As the brain, being the highest nervous centre, holds under its 
control in a large degree the lower bodily functions, it fol- 
lows that in insanity the conditions governing the best 
health of the body must often be violated, the result being 
perverted functions leading finally to serious bodily disease. 
Insane persons being thus susceptible to almost any disease, 
is it surprising that the one most likely to attack these 
people should be that which destroys more of the popula- 
tion than any other? Phthisis kills one-seventh of the 
people outside of asylums under most favorable circum- 
stances, so among the insane the rate would naturally be 
much higher. Most of the early writers upon this subject 
(among them Esquirol, Van der Kolk, Griesinger and 
others) believe there is a direct relation between insanity 
and phthisis. Dr. T. J. Mays, of Philadelphia, is convinced 
that the link which binds pulmonary phthisis to insanity 
and other neuroses is disease of the vagi. Van der Kolk 
expressed the same idea many years ago. This opinion, 
does not seem to be popularly accepted. A plausible view 
of the matter is, that these persons, being unstable in vary- 
ing degree, would be likely to break down in the direction 
of their greatest weakness. The result might be phthisis 
or insanity. In insane people suffering from phthisis the 
physical signs are often absent. In the beginning the 
patient is pale and loses flesh. In taking temperature, 
regular evening exacerbation and morning remission is 
found. Upon physical examination from week to week, no 
special symptoms can be noticed. There is no cough, expec- 
toration, or complaints of any kind, but the patient becomes 
gradually very weak. Loss of flesh and rise of temperature 
are the two sure signs when other symptoms are latent. 
Occasionally there is a typical racking cough, but this is 
uncommon. The appetite remains good unless, it may be, 
during the last week or two. This seems contrary to 
Clouston, Savage, Mann and others, who state, as a rule, 
tendency to refuse food with delusions of suspicion. The 
author has noticed but two cases of such delusions, though 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 223 

these did not refuse food. Dr. Phelps has noticed that 
chronic melancholia and dementia are the forms of insanity 
most liable to end in phthisis, as these diseases offer the 
least bodily resistance. Savage would also include general 
paresis in this class, but with this the author disagrees. 
Out of seventy-five cases of paresis in the hospital but one 
died with phthisis. From various statistics Dr. Phelps 
concludes the death rate in asylums from phthisis 
to be no higher than that in the population out- 
side, living under somewhat similar conditions. He 
notices no direct relation between insanity and phthisis 
other than insanity favors the production of phthisis by 
causing neglect of the body on the part of the patient. As 
modern asylums are planned with more reference to 
hygiene, and outdoor exercise of patients has been increased, 
the death rate from phthisis is lower than in former years. 
(Hospt. Bulletin of Second Minn. Hospt. for Insane, November.) 



Ambulatory Automatism in a Dipsomaniac. — Dr. Souques 
(Arch de Neur., July, 1892) reports the case of a periodical 
lunatic of degenerative ancestry in whom the subsidence of 
the dipsomaniac period was followed by automatic uncon- 
scious wanderings. 



J. G. KIERNAN. 



Insanity in Private Practice. — In a paper read before 
the Illinois State Medical Society, Dr. Dewey, of Kankakee, 
speaks of the ignorance of the average practitioner about 
insanity: the course of instruction in the medical schools 
does not seems to include intelligent treatment of this dis- 
ease, and in the minds of otherwise able physicians there is 
often superstition upon the subject. The only remedy for 
this is a thorough study of the anatomy, physiology and 
pathology of the brain and nervous system as revealed by 
the researches of recent years. By being thus ignorant of 
mental disease the general practitioner may make one of 
three common mistakes : first, he may hurry the patient off 
to an hospital when such a course is really unnecessary : 
second, he may keep the patient at home until some unfor- 
tunate casualty occurs, or until the most favorable time for 
treatment has passed away: third, in dealing with the case 
he may make an unwise use of powerful nervines, sedatives 
or narcotics, and he may resort to harsh measures of re- 



224 psychological. [December, 

straint, or indiscriminately indulge whims of patients and 
friends in such a manner as to be harmful. After making 
suggestions under these three heads the doctor concludes by- 
deprecating any deceitfulness in dealing with the insane, 
and by emphasizing the guiding principle which is needed 
more than any other in the treatment of such unfortunates, 
namely : "to treat them as far as possible in the same way 
in which we would treat a rational fellow-being or wish to 
be treated ourselves". 



Some Outlines of State Policy in the Care of the 
Insane. — In a second paper Dr. Dewey's purpose is to 
present ideas in relation to the general subject of the care 
and treatment of the insane, and on the construction, ad- 
ministration and organization of institutions for this class of 
citizens. After elaborating upon the foregoing topics the 
doctor summarizes as follows: "First. — The increase of 
insanity, and the large number now unprovided for, render 
it exceedingly desirable that a settled line of policy which 
will meet the requirements of humanity and economy, may 
be arrived at and generally agreed upon. Second. — Institu- 
tions were formerly provided which were ill-adapted for 
meeting the greatly varying conditions among the insane, 
and were too expensive in their construction. A reaction 
has taken place, and a notable change in the style of con- 
struction has grown up in the last ten or twelve years ; and 
simple, inexpensive,two-story buildings,much like anordinary 
house, have been found feasible for the great mass of the 
insane. Thus a greater degree of adaptability has been 
secured to the varying conditions of the insane. Third. — 
For good management and for the welfare of the insane, 
separate institutions are needed for certain classes ; namely, 
the insane criminals, the epileptic insane, and, where 
possible, the victims of alcohol, morphine, etc. Fourth. — In 
every institution having a large number of patients there 
are certain groups of patients which should have, by means 
of detached buildings, such separation as will minimize the 
evils of associating the insane. These groups are the cur- 
able patients who should be in " curative wards " especially 
constructed for them, the " habit " cases and those of 
neurasthenia (unless removed to a separate institution), the 
bodily sick and the infirm patients, and the refractory 
patients. By suitable arrangements the groups of buildings 



1892.] PATHOLOGY AND SYMPTOMATOLOGY. 225 

for these patients can be an integral part of the institution, 
near enough for good administration, yet separated so as 
to prevent injurious contact and association. Fifth. — 
The size of the institutions has been continually 
increasing, and the movement in this direction seems to be 
unavoidable. There are, however, advantages in the large 
size of institutions which compensate, in a measure, for the 
drawbacks. The insane, when associated in considerable 
numbers, fall into certain homogeneous groups, each suf- 
ficiently large to have buildings and surroundings proper 
to themselves ; while in smaller numbers such classification 
is impossible. Further, the great majority of the insane 
have been accustomed to very similar previous conditions 
of life, which admit of much uniformity in their care and 
surroundings. Incidental to the size of institutions, great 
stress should be laid on the importance of determining, 
when an institution is begun, what its ultimate size shall be. 
Sixth. — In the government and supervision of institutions 
for the insane, a Board of Charities, with advisory and 
supervisory powers, is to be preferred to a commission of 
lunacy with mandatory powers; and the Board of Chari- 
ties, as well as the boards of trustees or managers of insti- 
tutions, should be non-partisan and uncompensated. Such 
Boards should have a lawyer and a physician, and, where 
practicable, a woman, as members of the Board. Seventh. — 
County authorities should not have the care and control of 
the insane in whole or in part. The county government is 
not adapted for the insane, and a combination of State and 
county agencies is only an " entangling alliance." The 
State ought to be able to do anything that a county can do, 
and do it better. At the same time the county system, as 
originally established in Wisconsin, possessed elements of 
value worthy of imitation, especially in the frugality and 
industry secured. Eighth. — Voluntary or self-commitment 
of the insane is something that it is desirable to provide for 
in the commitment laws, as it is already done in several of 
the States. Ninth. — Training schools for the attendants are 
desirable in every institution for the insane. Tenth. — A 
woman physician should be a member of the medical staff 
of every large institution for the insane. Eleventh. — A large 
amount of scientific work is desirable as a feature of the 
work of institutions for the insane, and such work should be 
encouraged both by the State and by the management of 
the various institutions." 



226 psychological. [December, 

Some Illustrations of the Working of the Plea of 
Insanity in Criminal Prosecutions* — Dr. Dewey 
read a paper with the above title before The Chicago 
Medico-Legal Society, in which he presented several facts 
that had come to his knowledge as medical superintendent 
of a state hospital for the insane, illustrating the evasion of 
, the law by the plea of insanity. Medicine stands ready to 
do her worthiest for furthering the ends of justice, but is 
dependent upon law for her opportunity. Illinois and two 
or three other states have made a step in advance by 
establishing separate asylums for insane criminals, but this 
is of no avail where the plea of insanity is fraudulent. It is 
believed the present evils will exist as long as the ordinary 
method of obtaining testimony continues, namely : that of 
permitting each side in any given case to procure as 
witnesses whomsoever they list. The manner in which 
reform may be accomplished is one for kwyers and legisla- 
tors to discuss, but the essential object to be attained should 
be by the summoning of the court itself — and not by any 
party to any litigation — of persons capable of giving expert 
advice and assistance without reference to its bearing upon 
any personal interest, whose decisions should be authoritative 
and open to no doubt, either of dishonesty or incompetency. 
Dr. Dewey concludes by saying : "The failures of justice 
would be remedied, to a great extent, by a better system of 
regulating expert testimony, and especially by legally de- 
fining and restricting the functions of experts in such a 
manner that the expert shall be amicus curiae, an assistant to 
the court, and not, as sometimes happens, a suborned and 
hired accomplice to the prisoner's guilt". 



1892.] NOTES AMD COMMENTS. ^ 227 

EDITORIAL NOTES AND COMMENTS. 



Modern Methods. — There are many indications in medi- 
cal literature that the younger generation of physicians is 
finding practical use for the evolutionary philosophy in ex- 
plaining questions of physiology and pathology. The 
Platos and Spencers have long to wait before their teachings 
percolate through to practical life, for the plain worker does 
not readily see how their fine theories can help him to work 
easier or better. But, happily, the race is gaining rapidly 
in catholicity and adaptability of thought, and men now 
receive and apply with more readiness the results of philo- 
sophical teaching. This gain has quickened the pace of the 
century, has widened the horizon of thinking people, and 
has made Spencer and Heckel familiar, not alone to the 
cultured, but to such as shove the plane and carry the hod. 
The general acceptance of the evolutionary idea is not a 
craze, but has been a growth, and it promises to be the 
working basis for the future. It appeals not to sentiment, 
but to reason, and it appeals to reason because it explains 
the origin and meaning of life as we see it, how through an 
unvarying and beautiful order, and in obedience to a single 
law, nature has woven the complex fabric of organic struct- 
ure. And it shows, too, and this is the important point for 
the physician, how by a reversal of this order nature undoes 
by disease what growth has done, thus unraveling in an 
orderly way the complexities of structure. Many recent 
medical writers, notably Hughlings- Jackson, Maudsley and 
Mercier, have given a new interpretation to mental phe- 
nomena, both normal and morbid, because they have 
studied them by the light of the new philosophy. One 
gains vastly by having some theory on which to string his 
facts, for he thereby gets order and precision. The accu- 
racy and method of interpretation which the development 
theory furnishes is silently but rapidly modifying our views 
of mental pathology. While all investigations into the 
pathology of insanity are to be encouraged, there is certainly 
a limit to the revelations of the microscope, and we fancy it 
is in the unknown region beyond these limits that lie the 
pathology of insanity — if pathology it can be called. Gross 
lesions as the pathological basis of insanity reveal some- 
thing to be sure, what might be called the capes and prom- 
ontories of the unexplored region; but, after all, they 



228 /Notes and comments. [December, 

furnish but vague information of the molecular condition 
of nerve cells of which insanity is the symptom. Who 
hopes that the microscope will ever show us the pathologic- 
al condition of which melancholia and acute delirious 
mania are symptoms? It will probably never reveal the 
mystery, for the condition is, in last analysis, molecular, and 
is beyond the reach of the skill of the laboratory. The 
explanation will, however, come, and probably through 
various sources; through a better knowledge of comparative 
psychology, through an understanding of the mental evolu- 
tion of man and animals, and above all, in a thorough knowl- 
edge of the chemistry and physics of cell life. This kind of 
investigation requires technical knowledge applied to differ- 
ent orders of facts by many investigators working in differ- 
ent fields, and then the application of this vast knowledge 
to mental pathology. 

In this note we but indicate the direction in which pres- 
ent tendencies point. We believe that splendid results are 
to follow the new method, and hope it will furnish some- 
thing tangible and useful for the present theories of mental 
pathology, which are but a tangled brush heap of conflicting 
theories and unproved assertions. 

Weism ann's Theory of Heredity. — It is, perhaps, well 
that we are free to speculate and fill the scientific air with 
castles of theory, but this liberty often results in mon- 
strosities of opinion. When metaphysics was the fashion, 
speculation took the place of observation. It was the favor- 
ite pastime of the philosophers to juggle with "essences" and 
"potences" and other mysteries conjured by imaginations 
unhindered by facts. We of this generation have 
inherited a share of this spirit, and are still inclined to 
go beyond the phenomenal world even in matters of science. 
It is strange how often great minds find difficulty in getting 
rid of the disposition that is characteristic of the savage and 
primitively civilized state, to rest content with explaining 
complex things by some one general force or principle. To 
the savage the infinite exhibitions of nature's forces are ac- 
counted for by the assumption that behind them all is hid- 
den his capricious deities. How recently we have overcome 
this tendency the words "spirits" in our pharmacopoeia, and 
"phlogiston" in the chemistry of the last century show. 
Darwin's tendency to deify natural selection to the neglect 
of other elements of organic evolution, shows how hard it is 



1892.] SOTES AND COMMENTS. 229 

to grasp the complex and infinitely numerous factors of 
causation, especially as they relate to biology. Weismann's 
theory of heredity illustrates this tendency, for he comes 
j very near defy ing natural selection and adaptation. Weis- 
mann's theory is summed up in the formula of the "contin- 
uity of the germ-plasm". The theory is, that there is in the 
germ cell a substance of definite chemical and molecular 
structure from which reproduction takes place. In each re- 
production a part of the germ-plasm is not used up in the 
making of the new body, but is reserved unchanged for the 
making of the germ-cells of the next generation. Thus 
from the first organism throughont all the generations of 
the past there has been this continuity of the germ-plasm, 
and the process is to be continued throughout all the gener- 
ations of the future without loss of individuality to the 
germ-cell and without any modification of it from the con- 
ditions that affect the organism that bears it. In 
accordance with this theory there is no transmission 
of acquired characters, for if the germ-cell thus 
leads a charmed life in the body that temporarily 
bears it, unchanged by the ftBftfe itrio HB^JJ iat impress s » ,j* 

the organism of the parent, there will be no new characters ^^ 35 *^t-Jfj. 
to transmit. There is, apparently, a great deal of meta- 
physics in Weismann's theory. It is important to note that 
he does not speak of the continuity of germ-cells, but of the 
peculiar substance that cannot be seen by the microscope, 
nor can be demonstrated by chemical processes, which he 
chooses to call "germ-plasm". This substance, he holds, 
possesses continuity and sameness, and yet that it indefi- 
nitely reproduces itself. It is unchanged by the environ- 
ment, or by any changes in the organism that bears it, 
while at the same time it depends upon this organism for 
its nutrition. All this is sufficiently metaphysical to please 
even Sir William Hamilton. One is struck with the re- 
semblance of this theory to the pre-formation theory of Boer- 
haav, which taught that in every germ-cell was a model of 
a new organism, complete in all its parts, and in the germ- 
cell of this new organism another one, also complete, and so 
on for all successive generations in ever smaller miniature. 
If it could be demonstrated that modifications in the parent 
were, in one single instance, inherited by the offspring, this 
would disprove Weismann's theory, at least it would be a 
positive contradiction of the central idea. There seem to be 
a good many facts that contradict it. Dr. C. G. Lock wood 



230 notes and comments. - [December, 

has recently produced a race of tailless mice. He selected a 
pair and put them in a cage by themselves, and by clipping 
their tails off got a breed of tailless mice in the seventh 
generation. Then by taking one with a tail and one with- 
out a tail, and alternating the sexes in each generation, he 
finally again got a breed of all-tail mice. This looks very 
much like the inheritance of an acquired character, although 
Weismann says such things cannot happen. Brown-Sequard 
produced epilepsy in Guinea pigs by injury to the nervous 
system, and he found that this epilepsy was inherited. 
Weismann thinks that the best explanation of this is, that 
there was microbic poisoning of the parental germ, and that 
the inherited epilepsy was due to the transmission of mi- 
crobes. We are not aware that there is any authority, how- 
ever, for his opinion. "In some hot countries there are cer- 
tain species of trees protected against leaf-devouring ants by 
body guards of smaller ants. In the limbs of these trees, 
which are of different varieties, are found little chambers 
which serve the ants protecting the trees, for dwellings and 
breeding places." Now, are we to suppose that these cham- 
bers, found in various species of trees needing protection, 
are simply voluntary variations, or were they acquired by 
ants boring in the limbs, and later became hereditary? The 
latter explanation seems to us more reasonable. 

Weismann's theory is a complete reversal of all our ideas 
of heredity, and, while this is no argument against it, we 
cannot see that he has yet adduced sufficient evidence to 
sustain it. That acquired characters are inherited is in har- 
mony with universal experience. Of all the facts concern- 
ing the succession of organic life there is no one belief in 
favor of which there is such a large mass of facts. It is 
possible that these facts can be differently interpreted, and 
all attempts such as Weismann's should be welcomed. As 
yet, however, we cannot see that he has done so; nor can we 
see that his theory, even if correct, is any explanation of 
heredity, or even an approach to it. It explains one very 
complex, and as yet imperfectly understood phenomenon of 
nature, by invoking the aid of a mystery — the "continuity 
of the germ-plasm". 

A Retrospect. — A recent visit to the college where the 
writer graduated, naturally recalled student days and the 
old guard of medical men who gave to Bellevue its original 
fame. Many of us, then young and ardent, entertained 



1892.] NOTES AND COMMENTS. 231 

ambitions that have not been realized, but in the fading of 
these illusions we have learned that life keeps her promises 
to those who do not expect too much of her, and, too, we 
have learned to adjust our expectations to our capacities, and 
the homely, but stern, conditions of existence. It is doubt- 
less true that there is in our ambitions, as in our ideas, a 
selective process going on by which the fitter prevail. 
Those that are unadjustable to our life we first neglect and 
later are quite inclined to disown. It is, however, a pleas- 
ant experience to return to the old college and take an 
inventory of the professional years that bridge the interval. 
How crude those early ideas, how bewildering that jungle 
of medical facts and theories, and how slowly we gained a 
little system and order as experience was enlarged ! To the 
writer hereof there are no more pleasant memories, and 
none he esteems more valuable, than the personality of 
those college professors, the influence of which was a 
part of the benefit of the instruction. What student 
can forget Hamilton, the Chesterfield of the faculty, 
courteous, talented, and sincere, constitutionally incap- 
able of pretension ? In many respects he was an ideal 
man; able, bold and always positive in his opinions, he yet 
saw the good in others and did not hesitate to give due 
credit. He was, in himself, a positive educative force, and 
must have had a lasting influence upon the lives of many 
young men. Van Buren was also a fine type of man. His 
learning, experience, and the cheerful dignity that held in 
solution a quiet humor, gave him a strong hold upon the 
class and made him an impressive and valuable instructor. 
Intellectually vigorous and of large mental grasp he seemed 
also to embody the Greek requirement of the surgeon, that 
" he have an eagle's eye, a lion's heart, and a lady's hand". 
No less happy was the influence of Austin Flint, who was 
one of the great medical men of the century. His dignified 
and kindly manner adorned a strong character, and one 
that made itself felt in the college and also in the profes- 
sion throughout the country. These we have mentioned 
have "passed to the other side", but they completed a great 
work before they went. In the hurry of life's duties, and 
the narrowing tendency of competition, we are too apt to 
overlook the educative effect of human intercourse, 
the unconscious influence that one man has upon 
another. The great forces of the world work in 
silence and concealment, and in human relations the 



232 notes and comments. [December, 

anonymous and unmeasurable influences are no less im- 
portant than those that are more noticeable and the result 
of intentional effort. Lives like these are inspirations to 
those who have profited, not alone by their teaching, but by 
those intangible qualities that are not expressed in words 
and yet refine and elevate, and become a living force in our 
life. Such men were those we have mentioned. All honor 
to them for having blessed the world with their talent and 
character, and for having transferred to others some of those 
fine qualities that made their own lives just. 

Dr. H. M. Lyman and Dr. L. C. Gray. — It is seldom we 
have the opportunity of noticing two works of such merit 
as that by Dr. Lyman on Practice of Medicine, and that by 
Dr. Gray on Nervous and Mental Diseases, reviewed else- 
where in this issue. Rarely do we find in a work on medi- 
cine so many excellencies as in the one by Prof. Lyman. It 
combines brevity with a full treatment of subjects ; essen- 
tially conservative, it yet epitomises medical progress; 
though strictly practical, it is thoroughly scientific and is 
the summing up of the results of a large personal experi- 
ence by one who is a pains-taking observer and an accom- 
plished scholar. To the work by Dr. Landon Carter Gray 
every word of this is alike applicable. Embracing the 
entire field of which it treats it answers all the require- 
ments of a practical and scientific treatise, and is compact and 
closely written, without a fact omitted or a page too much. 
Though rigidly accurate it is easily comprehensible to the 
un technical reader, is thoroughly reliable and contains 
the results of latest investigations. We congratulate Drs. 
Lyman and Gray upon the completion of their tasks and 
predict the profession will not be slow to show their appre- 
ciation. 

Dr. S. C. Johnson. — The appointment of Dr. S. C. 
Johnson, of Hudson, as Surgeon-General of Wisconsin, was 
the best that could have been made and is universally 
acceptable to the profession of the state. As a leading 
practitioner in an extensive field, and as a surgeon for vari- 
ous railroad companies for many years, the doctor brings to 
the position two essential qualifications, the mental disci- 
pline of a large experience, and a kindly but vigorous 
personality. We congratulate General Johnson and hope 
his official career may be long and useful. 



1892.] NOTES AND COMMENTS. 233 

Dk. N. Senn. — Dr. Senn, who until recently was Surgeon- 
General of Wisconsin, has been appointed to a similar posi- 
tion in Illinois. It is a tribute to Dr. Senn that in each 
instance he was selected by a governor politically opposed 
to him. Dr. Senn showed what one man can accomplish in 
a short time, by his systematic reorganization of his depart- 
ment in Wisconsin and by the creation of the National Associa- 
tion of Military Surgeons. We predict the blood will soon 
begin to flow vigorously in the arteries of the Surgeon- 
General's department of the Illinois militia. 

Sensory-Motor Disturbances. — An article of more than 
usual interest, from the pen of Dr. H. A. Tomlinson, of 
Minn., appears in the October number of the Journal 
of Mental and Nervous Disease. The doctor discusses sensory- 
motor disturbances in their relation to molecular activity of 
the nerve cell. The article is an able one and illustrates the 
advantage of the modern methods that enable us to pene- 
trate beneath the surface of things. The man who studies 
successfully the mechanism of disease of the nervous sys- 
tem must be a scientist in its wider sense, and Dr. Tomlin- 
son seems to answer this requirement. 

A New Intestinal Operation. — Dr. M. E. Connell, of the 
Milwaukee County Hospital, published in the Med. Record of 
Sept. 17, an article on an improved technique in 
enterorrhaphy. ■ By this operation the doctor reduces the 
number of stitches to two, or even one. Having witnessed 
its application to dogs we can testify to its simplicity and 
efficiency, and predict for it a large field of usefulness in 
operations upon the intestinal tract. 



CORRESPONDENCE. 

Section of Neurology and Medical Jurisprudence, American 

Medical Association. 

Chicago, January 15, 1893. 
To Dr. J. H. McBride, 

Dear Doctor:— -The American Medical Association will 
meet at Milwaukee, Wisconsin, during the first week in June, 
1893, and as it is desired to make the meeting of the Sec- 
tion on Neurology and Medical Jurisprudence of the Associa- 
tion one of unusual interest and value, you are earnestly 
requested to contribute to this end by the presentation of a 



234 correspondence. [December, 

written communication on some neurological or medico-legal 
subject, or by bringing for exhibition and discussion anatom- 
ical or pathological specimens. 

If you have not yet chosen a subject, but are willing to 
take part in the work of the Section, please notify the Sec- 
retary at once of this intention, and as soon as possible 
forward the title of your contribution. It will facilitate the 
work of the Section to send an outline of your paper. A 
preliminary programme will be published during March. 

James G. Kiernan, M. D. 
834 Opera House Block, Chicago, 111. 

Officers of the Section.— Charles K. Mills, M. D., 1909 
Chestnut Street, Philadelphia, Pa., Chairman. James G. 
Kiernan, M. D., Chicago, 111., Secretary. 

Executive Committee. — 0. Everts, M. D., Cincinnati, 
Ohio: H. N. Moyer, M. D., Chicago, 111.; Justin E. Emerson, 
M. D., Detroit, Mich. 

REVIEWS, NEW BOOKS, ETC. 

A Text-book op the Principles and Practice of Medi- 
cine, for the Use of Medical Students and Practition- 
ers, by Henry M. Lyman, A. M., M. D., Professor of the 
Principles and Practice of Medicine in Rush Medical Col- 
lege, Chicago, 111. Witli one hundred and seventy illustra- 
tions. Philadelphia, 1892, Lea Brothers & Co. 

A work on the practice of medicine by one so long and 
favorably known as a teacher and author as Dr. Lyman, 
is sure of the careful attention of the profession. He states 
that the book is mainly the result of his own experience 
and observation. In order to adapt the work to the needs 
of the medical student, theoretical and historical matter 
has been omitted, the author confining himself to a concise 
statement of facts. The arrangement is to some extent 
novel. In the usual chapters on pathology, immunity, a 
new subject in textbooks on medicine, is sketched. Inflam- 
mation is stated to be usually microbic in character. The 
diseases caused by gross parasites are first considered, fol- 
lowed by those of known or suspected microbic origin. 
Although fibrinous pneumonia, which is attributed to the 
pneumococcus, is considered under diseases of the lungs, 
pulmonary phthisis is discussed under the head of tuber- 
culosis, together with all the other forms of " medical " 
tuberculosis. This latter arrangement is certainly more 



1892.] REVIEWS, NEW BOOKS, ETC. 235 

convenient, as well as more scientific than the usual one of 
running the results of one etiological factor upon various 
organs through an entire book. A great deal of stress is 
laid upon the local treatment of diphtheria by means of 
swabbing with mercuric chloride. Its internal use 
in large doses is not mentioned, although popular 
with some physicians. Instead, the internal use of turpen- 
tine is recommended. In the chapter on Tuberculosis 
almost two pages are devoted to scrofula, a word long ban- 
ished from modern medical literature. We cannot but be 
thankful to the author for rescuing this useful term from 
its threatened oblivion. He uses it to designate "that 
peculiar predisposition or diathesis which favors the occur- 
rence of tubercular infection " (p. 159). Syphilis is treated 
in a similar manner to tuberculosis, as an entity. Cerebral 
syphilis receives full treatment. In regard to treatment it 
is stated that " iodide of potassium should be given usually 
in five-grain doses three times a day, although many physi- 
cians advise * * * * one or even two drachms three or 
four times a day" (p. 211). Of course mercury and 
adjuvants are also recommended. The chapter on Cholera 
is full and thoroughly up to date. The very latest contri- 
butions to therapeutics appearing in periodical literature, 
such as hypodermoklysis, enteroklysis and the use of 
large doses of salol, being considered. An instructive 
chapter on the Management of Infective Diseases closes 
Part II. The subject of chronic gastric catarrh 
receives brief attention. The author states that in 
intussusception the results of operation have not been 
encouraging, while in intestinal obstruction and oc- 
clusion "the knife should be used as early as possible " 

(p. 367). It would be a very interesting task to go through 
the entire work seriatim if the space permitted, but the 
above notice must suffice to show the views of the author 
upon some subjects of general interest. The remaining 
chapters, upon the diseases of the various viscera as well as 
general diseases, are as full as the bulk and scope of the 
work allow. It is in Parts X to XIII, treating of Diseases 
of the Nervous System, that readers of this periodical will 
be most interested. These occupy over 161 pages, or nearly 
one-fifth of the volume, and open with a consideration of 
the diseases of the peripheral nerves. For acute 
multiple neuritis, salicylic acid in doses as large and 
as frequent as the patient will tolerate is ad- 



236 reviews, new books, etc. [December, 

vised. The coal tar preparations are also recom- 
mended. Acute ascending paralysis is classed with 
the functional diseases of the cord, as are professional 
spasm, tetany and Thomsen's disease. In the treatment of 
acute myelitis, iodide of potassium and the icebag are rec- 
ommended. The same treatment is suggested for multiple 
scleroses, which is treated quite fully in regard to symptom- 
atology and diagnosis. Spinal concussion and traumatic 
neuroses are considered together, but briefly. In regard to 
the etiology of locomotor ataxia, Dr. Lyman adopts the 
views of Erb and Strtimpell that " about ninety per cent, of 
the cases are dependent upon previous syphilis, though it 
probably bears the same relation to that disease that so 
many other nervous diseases sustain toward infective dis- 
eases generally" (p. 826). In the treatment, " ergot, 
belladonna and similar remedies should be avoided" (p. 
830). His experience with suspension has been the usual 
one. The section on Anterior Poliomyelitis, although 
short, is very good. The chapter on Bulbar Lesions is ac- 
companied by a full page illustration showing the location 
of the nuclei of the cranial nerves. In Part XII, devoted 
to Diseases of the Sympathetic Nerves and of the Muscles, a 
number of rare and interesting conditions, such as acrom- 
egaly, myxcedema, erythromelalgia, intermittent angioneu- 
rotic oedema and Raynaud's disease, are briefly sketched. 
The chapter on Localization and Diagnosis of Cerebral Lesions 
is very good indeed, and is accompanied by several clear 
diagrams which will materially aid the student in 
grasping this subject. This is especially true of 
the diagram after Eichhorst on page 872, which 
will no doubt help many through the mazes of 
the different varieties of aphasia. The author evidently 
does not believe that the lancet should be altogether aban- 
doned as he recommends its use in sunstroke when there is 
evidence of great venous stasis, and in cerebral hemorrhage 
where the pulse is full and there is evident congestion of the 
face and head. Encephalitis is described as resulting in 
either softening or abscess, the diffuse hemorrhagic variety, 
of which a number of cases have been recently reported as 
following influenza in Germany, not being noticed. Choked 
disc is stated to be of occasional occurrence in abscess. In 
infantile hydrocephalus, puncture and drainage of the cra- 
nium followed by compression is suggested. A considera- 
tion of a number of functional cerebral disorders, ranging 



1892.] REVIEWS, NEW BOOKS, ETC. 237 

from epilepsy to neurasthenia, closes the work. This book 
can be cordially recommended to the profession, not alone 
to the general practioner, but to the neurologist also, who 
will find the knowledge of his specialty well epitomized in 
its pages. In Dr. Lyman's connection with colleges, we believe 
he has filled, successively, every chair except that of surgery, 
an experience which few men have had, and fewer still 
could have met so successfully. This experience has fur- 
nished a rare foundation for a work on medicine and it has 
been well utilized. The author's position as Professor of 
Diseases of the Mind and Nervous System at Rush has 
given him opportunities as a specialist the results of which 
are on record here, to the great value of the book. Last, 
but not least, we are glad to commend the excellent literary 
style of the work. It is no exaggeration to say that no work 
on practice has appeared since the days of Thomas Watson 
written in such clear and beautiful English. We are the 
more happy to be able to record this fact because the aver- 
age medical work is sadly lacking in literary finish, indeed, 
the majority give one the sensation of riding over a corduroy 
road. The work of Professor Lyman furnishes not only 
profitable, but pleasant reading, and from preface to finis we 
feel the presence of a strong personality and the inspiration 
of an attractive style. The cuts are well executed, and the 
illustrations of diseased conditions are mainly from the au- 
thor's own clinical material. 



A Treatise on Nervous and Mental Diseases, for Stu- 
dents and Practicioners of Medicine. By Landon Carter 
Gray, M. D., Professor of Nervous and Mental Diseases in 
the New York Policlinic, etc. With one hundred and 
sixty-eight illustrations. Philadelphia, Lea Bros. & Co., 
1893. 

There is probably no department of modern medicine in 
which progress has been so marked in the last decade and 
in which refinement in diagnosis has reached such perfec- 
tion as in nervous diseases. Although we possess many 
good textbooks on this subject yet the advance is so rapid 
that each succeeding author has something new to tell. No 
apologies are needed for the appearance of this work. Its 
information is so exhaustive and yet so concise that the 
reader feels that he has learned all there is to know on the 
subject, while the bulk of the book is not unusual. The 



238 reviews, new books, etc. [December, 

author states that he does not assume previous knowledge 
of his subjects on the part of the reader. The book opens 
with a very clear and instructive chapter on the Anatomy of 
the Cerebro-Spinal Nervous System, illustrated by sixty 
figures. This is succeeded by a chapter on Electricity, which 
contains not only all that it is desirable to known of electro- 
diagnosis, but a great deal of detail in regard to the selection 
and use of batteries and accessories. He next considers 
Localization. He states (p. 122) that "it is being shown 
more and more clearly that the metaphysical entity which 
we call mind is dependent upon the structural integrity of 
the cortex as a whole". He never misses an opportunity of 
impressing upon the reader the important fact that hemiopia 
and hemianopsia are not the same. In regard to neuralgia, 
which is the first disease considered, he expresses the 
opinion that all the theories as to its pathology are purely 
speculative and are likely to remain so. Beri-beri is classed 
with multiple neuritis. Under the heading of Myelitis the 
author has grouped all the unsystematized inflammations 
of the cord. He has made the curious observation that 
"the lower orders of Germans and Irish have less recupera- 
tive power in myelitis than other races". Why this should 
be it is hard to imagine, as these nationalities certainly 
comprise the better part of our laboring populations and 
usually live under better hygienic conditions than the Poles, 
Italians and others. His main reliance in this disease is 
upon electricity. A very good description of caisson disease 
is given. Progressive muscular atrophy, he states, may be 
of three-fold origin : 1, it maybe due to a lesion of the 
trophic cells in the anterior horn ; 2, it may be purely 
muscular ; 3, it may be due to a combination of these 
lesions. Although the author regards syphilis as by far the 
most frequent cause of locomotor ataxia he does not think 
that it is due to cerebro-spinal syphilis in the majority of 
cases. In spite of the fact that he is rather an optimist in 
therapeutics he states that there is not a case on record to 
prove that the anatomical lesion of locomotor ataxia can be 
cured. He is " inclined to think that many of these cases " 
(of ataxic paraplegia) " are really cases of spinal syphilis". 
A good deal of space is devoted to syringomyelias. " It is 
now quite the fashion to report so-called cases of syringo- 
myelitis. But the significant fact stares us in the face that 
in not a single instance that I have been able to find has 
the diagnosis been made before death." In traumata of the 



1392.] REVIEWS, NEW BOOKS, ETC. 239 

cord he thinks that surgical interference should be prompt 
when decided upon, especially in those cases in which there 
is indubitable evidence of compression. In hypertrophic 
paralysis he has found massage to give great relief. In fact, 
he expresses the intention to treat his next available case with 
gentle and long continued massage combined with iodide 
of potassium and mercury. This he has thought practicable 
from a 'priori reasons but has not had a chance to carry it 
out. In all cases of intracranial growth the iodides and 
mercury should be pushed to saturation. But in all cases 
in which the growth is rapidly proceeding in spite of treat- 
ment an operation should be done. " But I am firmly con- 
vinced that we usually wait too long before operating." A 
temporary craniectomy, with a liberal exposure of the brain, 
and, if need be, careful incision of this organ, are advised. 
The same treatment should be carried out in cerebral 
abscess, which latter, however, gets rather scant treatment, 
only one and one-half pages being devoted to it as against 
fifteen to cerebral tumors. In epilepsy, also, especially 
when due to traumatism or to some recognizable lesion of 
the brain, he is in favor of operative measures. Again in 
hydrocephalus, " two pieces of bone, two or three inches 
across and three or four inches long from each side of the 
skull on each side of the median line" should be removed 
in order to relieve the compression. The effect, however, 
will be only temporary. In intracranial hemorrhage in 
full-blooded persons venesection is advised to the extent of 
ten to twenty ounces. " The immediate results are some- 
times startlingly beneficial." When he comes to speak of 
hyperemia and anaemia of the cord and brain he takes 
decided issue with the distinguished gentleman who has 
described these conditions so fully. In fact, some of his 
remarks are quite caustic and pointed. " The truth of the 
matter is, that our knowledge of nervous diseases has 
increased so rapidly within the last quarter of a century as 
to make it a matter of little surprise that the older authors 
should have attempted to satisfy their ignorant consciences 
by dubbing as hypersemia and anaemia the many puzzling 
symptoms which time has resolved into distinct symptom- 
groups. The most difficult of all phrases for the average 
scientist is, ' I do not know '. The disease must be labelled 
at any cost, and, once labelled it takes many years to rub 
out the brand" (p. 344). Again, in speaking of the 
■cerebral palsies of infancy he mentions Striimpell's 



240 reviews, new books, etc. [December, 

theory of a motor polio-encephalitis as "one of 
the most flippant pathological suggestions ever made 
in medicine". The author has found in cerebro- 
spinal syphilis the most satisfactory results from "a conjunc- 
tion of the iodides with the brilliant treatment that has 
been made known by Dr. Weir Mitchell under the name of 
'Fat and Blood Making', a therapeutical procedure that, in 
my humble opinion, will rank in coming years with the 
surgical revolution inaugurated by Lister" (p. 372). In 
epilepsy his main reliance is, of course, on the bromide 
salts, although he states that "trephining is a harmless pro- 
cedure under proper antiseptic precautions and may dis- 
close conditions which otherwise could not have been 
brought to light". He also calls attention to the important 
fact that epileptics will do well for a time upon any change 
of treatment, medical or surgical. The diseases described 
by various authors as "jumpers, myriachit, latah, and tic 
convulsif," are classified as palmus or twitches. Dr. Gray 
is a believer in the great possiblities of psychical medicine 
but is not at all extravagant in his claims. In hysteria, 
hypochondria, somnambulism, trance and catalepsy these 
measures are especially advised, and he is inclined to try it 
in the future in the occupation neuroses. The chapter on 
Neurasthenia, the largest in the work, is complete and ex- 
haustive. In the chapter on Hydrophobia, he expresses the 
firm conviction that there is such a thing as lyssophobia, or 
nervous rabies, and that it may cause death. A chapter on 
Certain Nervous Symptoms Common to Different Diseases, 
comprising vertigo, headache, insomnia and coma, follows. 
For this the inexperienced practicioner will be thankful, 
as these frequently present themselves as clinical entities. 
An interesting chapter of ten pages on the Medico-Legal 
Bearings of Traumatisms, in fact, on Traumatic Neuroses, 
closes the neurological section of the work. On reaching the 
part of the book devoted to mental diseases the reader is 
surprised to find that the author has omitted the two things 
formerly thought necessary as introductions to the subject, 
namely: a classification and a definition of insanity. He 
would impress upon the reader the folly of attempting a 
classification by mere symptoms. In this he is in very 
good company, for Wernicke has lately protested against 
teaching the student the "useless, nay, even detrimental art 
of crowding a clearly comprehended picture of a case into 
the Procrustean bed of an artificial classification". (This- 



1892.] REVIEWS, NEW BOOKS, ETC. 241 

Review, Sept. 1892, p. 90.) Chapters on Delusions and Hal- 
lucinations, Morbid Fears and Impulses, Sexual Perver- 
sions, and Simulation follow. In regard to the last, he 
states that it can only be detected by one who is thoroughly 
acquainted with the different types of insanity. The author 
has discovered that in simple melancholia, three symptoms 
are characteristic: a peculiar facies, obstinate insomnia, and 
a peculiar post-cervical ache. None of these alone, but two 
or all together, are pathognomic. In 175 cases all three 
were present in 54 per cent.; the post-cervical ache was ab- 
sent in 18 per cent.; the insomnia in ten cases. Isolation is 
insisted upon in melancholia. Opium is his main reliance 
for treatment. For the insomnia, his choice of drugs is:. 
sulphonal, chloralamid, urethan, paraldehyde and chloral,, 
in the order named. His favorite sedative in all cases of 
mental excitement is hyoscine in doses of 1-100 grain. 
Mania, which next follows, is rather shortly treated. The 
position of Katatonia as an independent disease it is stated 
is still subjudice, although the author seems to incline toward 
Kahlbaum's views. In Periodical Insanity, the author has 
seen good results from the use of cannabis indica. Furor 
Transitorius and Delirium Grave are each discussed. Epi- 
leptic Insanity, a subject of considerable medico-legal impor- 
tance, is rather fully considered. Hallucinatory Insanity 
and Hebephrenia both get rather short treatment at the 
hands of the author, while Paranoia and Paralytic Dementia 
receive the full consideration their importance requires. 
In all his cases of the latter disease a history of cerebral 
syphilis has been shown. Consequently, specific treatment 
should have a trial at the outset. The titles given above 
comprise the classification of insanity according to the 
author. In the chapter on Idiocy, which follows, he warns 
against a too enthusiastic adoption of the operation of 
craniectmy. An extremely interesting chapter, giving a 
resume of our knowledge of the Pathology of Insanity,, 
closes the work. The glossary appended will be highly 
useful to readers. The bibliography throughout is very 
full and bears witness to the author's great industry. We 
predict for this book a great and lasting popularity. 
While strictly scientific, it is essentially practical. The- 
language is simple and clear, the style charmingly easy 
and, at times, even conversational. The writer cannot 
recall one abstruse or. involved sentence. In his preface,, 
the author states that the leisure of seven years has been. 



242 reviews, new books, etc. [December, 

devoted to this work, yet no one can point out a section 
which is not wholly modern and up to date. While the 
author is not a medical Nihilist, his therapeutic enthusiasm 
is tempered by a calm judgment and a ripe experience. 
The illustrations are excellent, and mostly original. The 
usual stock diagrams and cuts used to illustrate these sub- 
jects being happily absent. On the whole, the American 
profession cannot but be grateful to the author for giving 
them this most valuable work upon a class of diseases, which, 
in spite of their prevalence, are perhaps least understood of 
any in the domain of practical medicine. One charm of the 
work is the feeling that behind it there is a strong personal- 
ity that presents in a vigorous and beautiful style, the ripe 
experience of an observer who is self-reliant and eminently 
practical. Comparisons between works by different authors 
on the same subject are not always just because each has its 
merits and its faults. Considering, however, the large 
scope of this work and the compactness that a reasonable 
brevity made necessary, we think the general verdict will 
be that Doctor Gray has written the best work on mental 
and nervous diseases that has ever appeared in the English 
language. 



A Study of the Artefacts of the Nervous System. 
The Topographical Alterations of the Gray and White 
Matters of the Spinal Cord Caused by Autopsy-bruises, 
and a Consideration of Heterotopia of the Spinal Cord. 
By Ira Van Gieson, M. D., Assistant in Histology at the Col- 
lege of Physicians and Surgeons, Columbia College, New 
York, etc. Reprinted from the N. Y. Medical Journal. New 
York: D. Appleton & Co., 1892. 

This work is rather revolutionary in character. It takes 
up a subject of great interest to the neurologist as well as to 
the pathologist, and demonstrates that the opinions held 
heretofore have no foundation. The work is systematically 
divided into sections. Section I is devoted to a considera- 
tion of malformations of the cord in general, both the con- 
genital and acquired. In Section II the author reviews the 
published cases of true heterotopia of the cord and medulla. 
Out of 31 published cases he has demonstrated that only 
six are cases of true heterotopia. To this list he adds two 
personal cases. Section III, on the methods of removing the 
cord at autopsies, and their relation to the production of ar- 



1892.] REVIEWS, NEW BOOKS, ETC. 243 

tificial malformations by bruises, will be appreciated by all 
who have attempted this most difficult task, or have wit- 
nessed it. He shows that it is almost impossible to remove a 
•cord, especially if at all softened, without some bruising. 
From a laboratory collection of cords and from routine au- 
topsies, the author, in Section IV, cites a number of cases of 
heterotopia unintentionally produced. Section V is devoted 
to a description of the results of experimental bruising of 
the human cord, both gross and microscopic. These results 
vary from the dislocation of a minute bit of gray matter to 
the transference to a different level of one or several gray 
horns, or a more or less complete duplication of the entire 
cord. Section VI contains an analysis of all the erroneous 
cases of malformation of the cord heretofore published. It 
is accompanied by reproductions of the original figures. A 
comparison of these figures with those of the author show- 
ing artificial heterotopia is most convincing. These cases 
are twenty-four in number and have been reported by ob- 
servers whose names are usually synonomous with careful 
observation. Section VIII treats of the diagnosis of spinal- 
cord bruises. The white fibers, even if not displaced, will 
show distortion due to traction and compression. This ar- 
ticle was abstracted in the last number of this Review. Dr. 
Van Gieson is to be congratulated upon the excellent and 
convincing results of his investigations. He has called at- 
tention to a source of error in the study of a subject which, 
even under the most favoraable conditions, is beset with 
many difficulties. Over 100 figures serve to enforce the 
author's conclusions. We would cordially recommend all 
who are engaged in post mortem work or in the study of the 
cord, to procure a copy of this work. 

Tuberculosis of Bones and Joints. By N. Senn, M. D., 
Ph. D., Professor of Practice of Surgery in Rush Medical 
College ; Professor of Surgery in the Chicago Polyclinic ; 
Attending Surgeon Presbyterian Hospital ; Surgeon-in-Chief 
St. Joseph's Hospital ; President of the American Surgical 
Association ; President of the Association of Military Sur- 
geons of the National Guard of the United States ; Perma- 
nent Member of the German Congress of Surgeons, etc. 
Illustrated with 167 Engravings (seven of them colored). 
In one handsome royal octavo volume, 520 pages. Extra 
cloth, $4.00 net; half-Russia, $5.00 net. Philadelphia, 
the F. A. Davis Co., publishers, 1231 Filbert street. 



244 ee views, new books, etc. [December, 

This work comes fully up to the high standard which 
the author has taught the profession to apply to all his 
work. As stated in the preface, " The object of the author 
has been to collect from recent literature the modern ideas 
on tubercular disease of bones and joints, and present them 
to the reader in a condensed form, mingled, in appropriate 
places, with the results of his own experience". That he 
has labored at this object with his usual untiring industry 
is demonstrated by the very large number of authors and 
papers quoted, while his extensive clinical experience 
entitles him to present his own views with authority. There 
is little or nothing worth knowing in regard to the subject 
that cannot be found in this work. Of especial interest to 
neurologists is the section on laminectomy for paraplegia 
following spondylitis, to which six pages are devoted. 
Various authorities differ as to its advisability but the 
operation is so new that it is still sub judice. The language, 
while necessarily condensed, is still explicit. The mechan- 
ical execution of the work, especially of the illustrations, is 
excellent. 

The Student's Quiz Series. Practice of Medicine. A 
Manual for Students and Practicioners, by Edwin T. 
Doubleday, M. D., and J. Darwin Nagel, M. D. Series 
edited by Bern. B. Gallaudet. Philadelphia, Lea Bros. & Co. 
This little volume is one of the best of the many short cuts to 
knowledge which have appeared during the past decade. 
Its information is modern, and although arranged in ques- 
tions and answers the latter are so explicit that the 
questions might well have been omitted. The section on 
nervous diseases comprises one-fifth the book and seems to 
give all the information needed by the student while cram- 
ming for examination. This, indeed, is the main reason for 
the existence of this class of books. The great danger lies 
in the fact that students are too apt to rely upon such works 
instead of studying larger and fuller treatises. 



Diseases of the Lungs, Heart and Kidneys. By N. S. 
Davis Jr., A. M., M. D., Professor of Principles and Practice 
of Medicine, Chicago Medical College, etc. Philadelphia 
and London, 1892, the F. A. Davis Co., Being No. 14 in the 
Physician's and Student's Ready Reference Series. This 
little volume is an amplification of the author's lecture 



1892.] REVIEWS, NEW BOOKS, ETC. 245 

notes upon the same subjects. It contains a large amount 
of information in a small space and is especially full in 
regard to therapeutics. The author uses the metric system, 
but gives the equivalents in tli€ troy weight. This, in our 
opinion, is a mistake. The metric system is, or should be, 
so well known by this time that every physician or student 
should be able to use it. The only way to ever make its 
use universal in the profession is for authors to use it alto- 
gether, discarding the old weights. Until this is done there 
will always be practitioners too indolent to become ac- 
quainted with it. The work can be cordially recommended 
to all who require a book of the kind for hurried reference. 



Reform in the Treatment of the Insane. Early His- 
tory of the Retreat, York ; its Object and Influence, 
with a Report of the Celebration of its Centenary. 
By D. Hack Tuke, M. D., LLD., formerly Visiting Physician 
to the Retreat. London, L. & A. Churchill. The founda- 
tion of this litte book is an essay by Dr. Hack Tuke at the 
first centennial celebration of the York Retreat, May 6, 
1892. The grandfather of the author was the founder of 
this institution, and was one of the brave men who inaugu- 
rated reform in the treatment of the insane and took the 
first steps toward developing modern methods in caring for 
them. The book is primarily a history of the elder Tuke 
and his struggles for reform ; seeondarily, a sketch of the 
progress of reform. The age of the elder Tukes marks an 
epoch in insane hospital history, and their worthy descend- 
ant has epitomized it in this essay. The book is interesting 
and instructive reading. 

Syphilis and the Nervous System, being a Reprint of 
the Lettsomian Lectures for 1890, Delivered before the 
Medical Society of London. By W. R. Gowers, M. D., F. 
R. C. P., F. R. S. Philadelphia, P. Blakiston, Son & Co. 
This book comprises all the lectures upon this subject deliv- 
ered in 1890 by Dr. Gowers, republished with many addi- 
tions. In the three lectures contained in the book the 
author speaks, first, of the pathology of syphilis, secondly, 
of the origin of functional nervous disorders attributed to 
it, and thirdly, of its prognosis. This work is thorough 
and progressive and omits nothing that is of importance. 
We commend it to the profession as a valuable epitome of 
the subject. 



246 reviews, new books, etc. [December,, 

A Manual of Medical Jurisprudence. By Alfred 
Swaine Taylor, M. D., F. R. S. Revised and edited by 
Thomas Stevenson, M. D., London. Eleventh American 
edition by Clark Bell, Esq. Philadelphia, Lea Bros. & Co. 
Mr. Clark Bell has rendered a valuable service to the pro- 
fession in editing a new edition of this important work. It 
stands at the head of works upon this subject and is one 
which every physician should have in his library. This 
edition brings it down to date and every subject is discussed 
fully and ably. 

La Revista Medico-Qulrurgica. — This journal has an 
able corps of collaborators and will, doubtless, have a field 
of usefulness. It is the official Spanish organ of the Pan- 
American Medical Congress. 



The U. S. Pharmacopoeia, "1890" which will be published 
during 1893, adopts in great measure the Metric System of 
weights and measures; this will, doubtless, create much 
confusion in the minds of physicians and druggists and 
lead to many misunderstandings and errors. In order to 
provide a guide to the proper dosage, etc., Dr. Geo. M. Gould, 
author of "The New Medical Dictionary", has prepared a 
very complete table of the official and unofficial Drugs, with 
closes in both the Metric and English systems ; this table is 
to be published in P. Blakiston, Son & Go's. Physicians' Vis- 
iting List for 1893, together with a short description of the 
Metric System. 

The Messrs. Macmillan & Co., announce that the re- 
cently completed edition of Foster's Text-Book of Physiology 
in four parts is to be supplemented by the issue of an 
appendix on "The Chemical Basis of the Animal Body," 
by A. Sheridan Lea, Sc. D., F. R. S. Dr. Lea is Lecturer on 
Physiology to the University of Cambridge, England. 



PAMPHLETS AND REPRINTS. 

On the Localization of the Auditory Centre — By C. K. 
Mills, M. D. 

A Contribution from Brain Surgery to the Study of the 
Localization of the Sensorv Centres in the Cerebral Cortex — 
By P. C. Knapp, A. M., M. D. 



1892.] PAMPHLETS AND REPRINTS. 24T 

A Case of Abscess of the Temporo-Sphenoidal Lobe, and 
of the Middle Lobe of the Cerebellum — F. P. Norbury, M. D. 

Tumor of the Brain— J. T. Eskridge, M. D. 

Bilateral Facial Paralysis — M. Imogene Bassette, M. D. 

Eye Paralysis— J. A. Jeffries, M. D. 

Intermittent Hysterical Paralysis — L. Bremer M. D. 

The Paralyses in Children which occur During and After 
Infectious Diseases — M. Imogene Bassette, M. D. 

Myotonia and Athetoid Spasm — C. K. Mills, M. D. 

Criminal Responsibility in the Early Stages of Paralysis 
— F. P. Norbury, M. D. 

Local Anaesthesia as a Guide in the Diagnosis of Lesions 
of the Lower Spinal Cord— M. Allen Starr, M. D., Ph. D. 

Early Diagnosis of Spinal Caries — Stanton Allen, M. D. 

Researches upon the ^Etiology of Idiopathic Epilepsy — C. 
A. Herter, M. D., and E. E. Smith, Ph. D. 

Remarks Concerning Some Unusual Features of Epilepsy, 
Together with Description of Some of its Unfrequently Rec- 
ognized Symptoms — C. Eugene Riggs, A. M., M. D. 

Recent Progress in Diseases of the Brain and Nervous 
System— F. Robert Zeit, M. D. 

Some Points on the Diagnosis and Nature of Certain 
Functional and Organic Nervous Diseases — J. T. Eskridge, 
M. D. 

On the Reflex Theory in Nervous Disease — L. Bremer, 
M. D. 

A New Consideration of Hereditary Chorea — R. M. 
Phelps, M. D. 

Nervo- Vascular Disturbances in Unacclimated Persons in 
Colorado— J. T. Eskridge, M. D. 

Subacute Recurrent Multiple Neuritis — J. T. Eskridge, 
M. D. 

The Affect of Arterio-Sclerosis upon the Central Nervous 
System— G. J. Preston, M. D. 

Myelitis in a Case of Incipient Posterior Spinal Sclerosis 
—J. T. Eskridge, M. D. 

Grave Forms of Purpura Hemorrhagica — J. H. Musser, 
M. D. 

Pachymeningitis Hemorrhagica Interna Chronica — F. C. 
Hoyt, M. D. 

Gonorrhceal Ophthalmia through Infection by Medium 
of an Artificial Eye — H. V. Wurdemann, M. D. 

A Case of Cerebral Syphilis— F. C. Hoyt, M. D. 

Tuberculous Ulcer of the Stomach — J. H. Musser, M. D. 



248 pamphlets and heprints. [December, 

On the Gastric Disorders of Pulmonary Tuberculosis — J. 
H. Musser, M. D. 

Typhoid Fever in the Light of Modern Research. — Facts 
and Doubts about Cholera — L. Bremer, M. D. 

Some Clinical Remarks on Dysentery — J. H. Musser, 
M. D. 

A Contribution to the Study of Cystic Kidney — Ludwig 
Hektoen, M. D. 

Observations on the Excretion of Uric Acid in Health and 
Disease — C. A. Herter, M. D. 

Whooping-Cough ; Its Management; Its Climatic Treat- 
ment— J. H. Musser, M. D. 

The Curability of Narcotic Inebriety — J. B. Mattison, M. D. 

The Sanitarv Side of the Drink Problem — T. D. Crothers, 
M. D. 

The Limitations and the Powers of Therapeutics — J. H. 
Musser, M. D. 

Laboratory Notes of Technical Methods for the Nervous 
System — Ira Van Gieson, M. D. 

The Value of Proteid in Certain Forms of Nervous Dis- 
ease — C. Eugene Riggs, M. D. 

The Treatment of Epilepsy with Special Reference to the 
Use of Potassium Bromate, Magnesium Bromide, Nitro- 
Glycerine, Antifebrin, Sulfonal, Etc. — Guy Hinsdale, M. D. 

Chloralamid ; The Treatment of Insomnia — Joseph 
Collins, M. D. 

Codeine in the Treatment of Morphine Disease — J. B. 
Mattison, M. D. 

Sulphide of Calcium, or Calx Sulphurate in Tonsillitis — 
F. P. Norbury, M. D. 

The Oxygen Treatment — John Aulde, M. D. 

Sources of Failure in the Use of Oxygen — S. S. William, 
A. M., M. D. 

Aphasia Due to Sub-dural Hemorrhage Without External 
Signs of Injury; Operation; Recovery — L. Bremer, M. D. 
and N. B. Carson, M. D. A contribution to Brain-Surgery — 
Jacob Frank, M. D. and Archibald Church, M. D. 

Some Practical Points in the Diagnosis of Spinal-Cord 
Lesions — Frederic Peterson, M. D. 

An Operation for the Radical Cure of Stricture of the 
Lachrymal Duct with Description of a Stricturotome — C. H. 
Thomas, M. D. 

Necessity for Removal of Ptregia before Operations Re- 
quiring Corneal Incision.— H. V. Wurdemann, M. D. 



1892.] PAMPHLETS AND REPRINTS. 249 

Cauterization in Hyperthopic Rhinitis. Condylomata of 
the Auditory Canal — H. V. Wurdemann, M. D. 

Tracheotomy vs. Intubation — W. F. Whyte, M. D. 

An Experimental Contribution Looking to an Improved 
Technique in Enterorrhapy, Whereby the Number of Knots 
is Reduced to Two, or even One — M. E. Connell, M. D. 

Two Cases of Conservative Surgery — F. R. Zeit, M. D. 

Abdominal Section for Diagnostic Purposes — Clinton 
dishing, M. D. 

Surgical vs. Educational Methods for the Improvement of 
the Mental Condition of the Feeble-Minded. — F. P. Norbury, 
M. D. 

Medical Manhood and Methods of Professional Success — 
C. H. Hughes, M. D. 

Annual Announcement of the Keokuk Medical College, 
Session 1892, 1893. 

Annual Announcement ot the Detroit College of Medicine, 
Session 1892, 1893. 

Report of the Board of Trustees of the Eastern Michigan 
Asylum at Pontiac for the Biennial Period Ending June 30, 
1892. 

NEW PERIODICALS. 

Condensed Extracts (Monthly) from the latest Foreign 
Medical and Pharmaceutical Journals. 

McCaskey's Clinical Studies. Published quarterly. From 
the clinical notes of G. W. McCaskey, A. M., M. D. 



MISCELLANEOUS. 

Cocillana — An Interesting Addition to the Materia 
Medica. — Respiratory inflammations always form a large 
proportion of the physician's cases. A Bolivian remedy 
which gives promise of much therapeutic efficacy is Cocillana, 
which was introduced a few years ago through the researches 
of Professor H. H. Rusby, the eminent botanist. Experi- 
ments were made with it by many medical investigators, 
who found its action very satisfactory in catarrhal inflam- 
mations of the respiratory organs, in coryza, hay asthma, 
bronchitis, acute and chronic, influenza and pneumonia. It 
possesses also laxative and purgative qualities and has been 
employed successfully as a substitute for ipecac and apomor- 
phia in catarrhal conditions. 

Parke, Davis & Co., who introduced the remedy to 



250 miscellaneous. [December, 

physicians, will supply reprints of articles affording infor- 
mation concerning its therapeutic application, and invite 
the medical profession to test its virtues further by clinical 
experiment. They have after much difficulty obtained an 
ample supply of it, and will be glad to afford any facts 
desired concerning this or any other of their new remedies 
for respiratory affections. 

Among other new remedies Lehn and Fink are prepared 
to furnish the trade with phenocoll, thiol and chloralamid, 
whose therapeutic action is well-endorsed as follows : 

Phenocoll in the Treatment of Malaria. — Phenocoll, a 
derivative of phenacetine, has been tried by P. Albertoni 
(La Riforma Medica, February 5, 1892 ; Revue de Therapeutique 
Generate et Thermale, June 5, 1892) in thirty-four cases of 
malaria. A permanent cure was obtained in twenty-four ; 
in five the results were doubtful ; and in the other five the 
drug failed to do any good. Some of the patients cured by 
phenocoll had suffered severe relapses after treatment with 
quinine. Pnenocoll was given in form of powder, in doses 
of fifteen grains (one gramme) six or seven hours before the 
expected paroxysm, and after the disappearance of the 
paroxysms, to prevent relapses the medicament was con- 
tinued for some time after. The new remedy has no un- 
pleasant after effects, and the taste is easily disguised by 
mixing it with sugar. In this manner children take it 
readily.— (Univ. Med. Mag., Sept., 1892.) 

Thiol in Infantile Therapeutics. — Dr. Moncorvo has 
employed this new antiseptic agent in more than one 
hundred infantile cases for the purpose of diminishing sup- 
puration and for the removal of cutaneous growths, either 
of parasitic origin (tinea tonsurans, favus, pityriasis, etc.). 
Thiol may be used with equal efficiency in the dry form 
(thiol powder), pure or rubbed up in vaselin (5 to 10 per 
cent.), or in liquid form, pure or diluted with boiled steril- 
ized water. The topical use of thiol was never followed by 
the least untoward local, or general effect. The therapeu- 
tical effect was satisfactory in every case. It was used, with- 
out fear of danger, on the youngest children. (The author 
has used thiol in the treatment of erysipelas and lymphan- 
gitis, in adults, with the greatest success.) — The Satellite. 



1892.] MISCELLANEOUS. 251 

Dr. Montague Gunning used a solution of chloralaruid 
with potassium bromide in two cases of sea-sickness with 
most satisfactory results. The first case was that of a gen- 
tleman who previously had never suffered from the affec- 
tion. After the vessel had left land about three hours he 
began retching and continued doing so for three hours. Dr. 
Gunning then prescribed the chloralamid solution, which 
gave immediate relief, bringing on refreshing sleep from 
which the patient awakened practically recovered. The 
other victim was a lady who had suffered for hours, but 
who slept for an hour after one dose of the remedy and was 
not again troubled with sea-sickness. The author was so 
favorably impressed with the action of the remedy that he 
hastened to call attention to it in the British Medical Journal. 
There is now a good quantity of evidence of this kind. 



NEUROSINE. 

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ANODYNE AND HYPNOTIC. 



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A RELIABLE AND TRUSTWORTHY REMEDY FOR THE RELIEF OF 

HYSTERIA, EPILEPSY, NEURASTHENIA, MANIA, CHOREA, 
UTERINE CONGESTION, MIGRANE, NEURALGIA, 
ALL CONVULSIVE AND REFLEX NEUROSES, 
THE REMEDY PAR EXCELLENCE IN DELIRIUM AND REST- 
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Potassium, Sodium and Ammonium, 1-8 gr. Bromide Zinc, 1-64 gr, each of 
Ext. Belladonna and Cannabis Indica, 4 grains Ext, Lupuli, and 5 minims 
fluid Ext. Cascara Sagrada, with Aromatic Elixirs. 

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Vol. III. MARCH-JUNE, 1893. Nop. 3 & 4. 



THE REVIEW 



OF 



Insanity # Nervous Disease 



A Quarterly Compendium of the Current Literature 
of Neurology and Psychiatry. 



EDITOR: 

JAMES H. MCBRIDE, M. D., 

MILWAUKEE, WIS. 



MANAGING EDITOR: 

G. J. KAUMHEIMER, M. D., 
Milwaukee, Wis. 



ASSOCIATE EDITORS. 

LANDON CARTER Gray, M. D., New York; C.K.Mills, M.D., Philadelphia; 
EUGENE Rtggs, M. D., St. Paul, Minn. ; W. A. JONES, M. D., Minneapolis, 
Minn. ; H. M. BANNISTER. M. D., Hampton, Ct. ; D. R. BROWER, M. D., 
H. M. Lyman, M. D., J. G. Kiernan, M. D., Archibald Church, 
M.D., Sanger Brown, M.D., S. V. Clevenger, M. D., Rich- 
ard Dewey, M. d., Chicago; Frank r. Fry, M. D„ L. 
Bremer, M. D„ St. Louis. 

MILWAUKEE: 

RIVERSIDE PRINTING CO., PRINTERS. 

1893. 



INDEX. 



Original Article— Nervous Dyspepsia, - - 255-264 

By H. L. Lyman, M. D. 

Neurological — 

Anatomy and Physiology, - 266-272 

Pathology and Symptomatology, - - 272-328 

Therapeutics, - -"" '"- - -' - 329-340 

Surgery and Traumatic Neuroses, - - 340-357 

Psychological — 

Pathology and Symptomatology, - - - 357-374 

Therapeutics, - -,. ,, .- - - 374-384 

Editorial, - - - - - - 385-393 

Asylum and Hospital Reports, .*.w. - - 393-394 

Notes and Comments, 394-396 

Book Reviews, - - - - - - 396-399 

Pamphlets and Reprints, -...-. r - 399-402 

Miscellaneous, - - - - - - 402-404 



The Review 



OF 



Insanity and Nervous Disease. 

FOR MARCH and JUNE, 1893. 

NERVOUS DYSPEPSIA. 

By H. L. Lyman, M. D. 

Professor Principles and Practice of Medicine and of Diseases of the 
Nervous System, Rush Medical College, Chicago. 



Nervous Dyspepsia comprises those disturbances of gas- 
trointestinal digestion that are chiefly dependent upon dis- 
order of the nervous system. By a large class of patholog- 
ists such disturbances are assigned to the category of inflam- 
mations involving the mucous membrane of the stomach and 
small intestine ; for such observers dyspepsia is merely the 
result of a catarrhal gastro-enteritis. But careful investiga- 
tion leads equally competent students to the belief that in 
in many cases inflammation plays only an inconsiderable 
or secondary part among the causes of disorder. It is prob- 
able that the relation between nervous disturbances in the 
alimentary canal and inflammation of its mucous membrane 
is not unfrequently analogous to what is sometimes observed 
in the laryngeal cavity when muscular rheumatism tempo- 
rarily invades the laryngeal muscles, producing hoarseness, 
or aphonia, without inflammation of the superjacent mucous 
membrane. In such cases it is also frequently observed that 
a slight and transient inflammation may be manifested in 
the mucous membrane at some considerable time (a day or 
two) after the commencement of convalescence from the 



256 nervous dyspepsia. [March-June, 

rheumatic attack. In like manner severe pain and disor- 
dered secretion may exist in the gastro-intestinal canal when 
no other symptom of inflammation can be demonstrated ; 
and only after a protracted period of disorder do such«ymp- 
toms sometimes make their appearance. 

Chemical examination of the contents of the stomach 
indicates considerable variation in the quality of the gastric 
juice when a patient suffers from disorders of digestion. 
Dyspepsias have been therefore subjected to a chemical 
classification, in which the relative variations of hydro- 
chloric acid play an important part. But in many instances, 
the clinical observers discover evidences of disordered diges- 
tion without any notable variation from the normal quantity 
of organic or mineral acid that should be present in the gas- 
tric juice. In other cases there is an excess of hydro-chloric 
acid; while in a third class, even though there be present 
an excessive quantity of organic acids in the contents of the 
stomach, the gastric juice is deficient in hydro-chloric acid. 
It will be convenient to consider these three classes in 
succession. 

(1) Simple Nervous Dyspepsia. — This form of dyspepsia 
is encountered among neuropathic subjects, and among 
members of the great arthritic family. These patients are 
predisposed to gout or to rheumatism, diabetes, polyuria, 
asthma, palpitation and irregularity of the heart, varicose 
veins, haemorrhoids, gall stones, gravel, premature bald- 
ness, whitening of the hair, dandruff, eczema, and neural- 
gia. Nervous dyspepsia frequently is associated with, or 
replaces the manifestations of muscular and nervous rheu- 
matism. The dyspepsia that is thus inaugurated is one of 
the most common causes of neurasthenia. 

The amount of free hydro-chloric acid in the gastric juice 



1893.] BY H. M. LYMAN, M. D. 257 

may be either normal or somewhat reduced in quantity 
without considerably affecting the nutrition of the patient, 
provided that intestinal digestion continue intact. Under 
such circumstances mere chemical examination of the gas- 
tric juice can afford very little information regarding the 
ultimate result of the digestive process. Of far greater im- 
portance is the condition of the nervous system, and the de- 
gree of perfection with which intestinal digestion is accom- 
plished. So long as dilatation of the stomach does not 
exist there will be no unusual delay in the passage of food 
to the intestine, there will be no fermentation, and no 
special failure of health, even though the amount of free 
hydro-chloric acid in the gastric juice fall considerably low- 
er than the normal standard. 

In this form of dyspepsia the general appearance of the 
patient exhibits little change. There is usually complaint 
of epigastric uneasiness after eating, accompanied by a 
sense of distension in the stomach, and by frequent eructa- 
tions of tasteless and odorless gas. Sometimes there is a 
feeling of difficulty in the act of respiration; the head aches; 
the countenance is flushed; the bowels are constipated, and 
haemorrhoids are often developed. Considerable pain is 
frequently experienced shortly after eating; it is a dull, 
vague distress that is not definitely located, but is experi- 
enced with varying severity in an ill-defined region beneath 
the diaphragm. Sometimes the patient experiences vertigo 
and sensations of constriction about the cranium; occasion- 
ally the temporal arteries beat violently, and the corres- 
ponding veins become distended with blood. In some in- 
stances it becomes impossible to lean forward without severe 
pain in one or both sides of the head. Sometimes there is 
a feeling of weight, or pressure in the occipital region; and 



258 nervous dyspepsia. [March-June, 

it is not an uncommon thing to hear a cracking sound in the 
articulations of the neck when the head is rotated upon the 
axis. Accompanying these symptoms there is usually great 
depression of spirits, and the patient is tormented by a fear 
of impending evil. Such patients not unfrequently exhibit 
great instability of feeling, and rapidly pass from an ex- 
treme of exaltation to the profoundest depths of depression. 

Examination of the abdomen an hour or two after meals 
discovers considerable gastro-intestinal distension with gas. 
Sometimes a succussion note is audible in the stomach, if 
the body be violently shaken. The distinction between dis- 
tension of the stomach thus produced and genuine dilatation 
of that organ can be made apparent by abdominal percussion 
in the morning before breakfast, at which time in simple 
distension succussion sounds are absent, whereas they can 
be always demonstrated in cases of persistent dilatation. 

Palpation of the abdominal walls seldom indicates any 
extensive tenderness or special uneasiness under pressure. 
A moderate degree of tenderness can be frequently detected 
just below the point of the ensiform cartilage, and in rheuma- 
tic subjects the upper third of the recti muscles is often 
sensitive under manipulation. 

The disturbances of digestion are not limited to the stomach 
alone; they also involve the intestinal tube. In many cases 
there is considerable distension of the colon; constipation 
and haemorrhoidal difficulties afford evidence of intestinal 
and hepatic disorder. Occasionally the symptoms of pseudo- 
membranous enteritis are developed. 

(2) Nervous Dyspepsia with Excess of Hydrochloric 
Acid. In certain cases of nervous dyspepsia there is an exag- 
gerated secretion of hydro-chloric acid. This condition is not 
uncommon in gastric neurasthenia. The excess of acid that 



1893.] BY H. M. LYMAN, M. D. 259 

is thus produced as a consequence of nervous dyspepsia some- 
times becomes a veritable cause of inflammation. Such exces- 
sive secretion is not uncommon during the paroxysms of vom- 
iting that sometimes occur during the course of tabes dorsalis. 
In typical cases of nervous dyspepsia accompanied by 
excessive secretion of hydro-chloric acid there is great pain, 
which commences two or three hours after eating, and is lo- 
cated in the epigastric region. This pain is greatly relieved 
by swallowing a liquid, such as milk, or an aqueous solution 
of an alkaline salt. It is arrested by the following meal, but 
begins again a few hours after the repast. In this way the 
latter part of the night is frequently filled with distress be- 
tween the hours of two and five o'clock in the morning; sleep 
is rendered impossible by burning pain or by vague sensa- 
tions of uneasiness in the epigastrium, sometimes irradiating 
into the interscapular space. In severe cases vomiting may 
occur; the patient sometimes provokes this act in order to 
relieve the distress that is caused by the accumulation of acid 
liquids in the stomach. Irrigation with the gastric catheter 
affords great relief, and is willingly practiced by the experi- 
enced sufferer. In many cases there is eructation of the 
acid contents of the stomach, causing intense pain and burn- 
ing sensations in the oesophagus and fauces. Such patients 
experience considerable thirst; their appetite is usually ex- 
cellent, and frequently exhibits an eager craving quality 
rendering it necessary to take food more frequently than in 
health ; they instinctively prefer animal food because it is 
digested more easily than a vegetable diet. There is usually 
considerable loss of flesh; the skin assumes an earthy hue, 
and nervous exhaustion is indicated by irritability, fatigue, 
restlessness, and inability to sleep. Many of these sufferers 
are exceedingly hypochondriacal and despondent. 



260 nervous dyspepsia. [March-June, 

The milder forms of the disease are characterized by less 
experience of pain. There is merely a sensation of epigas- 
tric uneasiness three or four hours after a meal; and comp- 
lete relief is afforded by the following repast. These patients 
require food at short intervals, and if the usual meal time is 
passed without food there is a feeling of exhaustion and dis- 
tress at the pit of the stomach, a throbbing head-ache, and 
vertigo. These patients are frequently rheumatic, nervous, 
irritable, and neuralgic. The bowels are usually constipated, 
though sometimes there is diarrhoea, especially during the 
night or early in the morning. Sometimes there is comp- 
laint of weight and distension in the region of the stomach; 
tenderness on pressure is experienced over the pyloric orifice, 
and distension of the stomach can be generally determined 
by percussion over the organ. When actual dilatation has 
occurred a succussion sound can be obtained in the morning 
before food has been taken. If the stomach be evacuated by 
aid of the gastric catheter the liquid that is thus obtained is 
strongly acid, ropy, and of a yellowish color. The fact of 
excessive secretion of hydro-chloric acid maybe conclusively 
demonstrated by washing out the stomach at bed time and 
on the following morning removing the liquid contents of 
the viscus before food has been taken. If hydro-chloric acid 
be present, there is hyper-secretion and gastric dilatation. 

In certain cases accompanied by excessive secretion of 
hydrochloric acid the patient is tormented by repeated 
paroxysms of vomiting which may continue for several days 
at a time. Such attacks are frequently experienced after 
intellectual fatigue, and are an expression of nervous disor- 
der that is accompanied by head-ache, pain in the stomach, 
and nausea; symptoms that are relieved by vomiting the 
excessively acid contents of the stomach, or by their neutral- 
ization with an alkaline solution. 



1893.] by h. m. lyman, m. d. 261 

(3) Nervous Dyspepsia with diminished secretion of 
Hydrochloric acid — In the third form of nervous dyspep- 
sia the amount of hydrochloric acid, both free and combined, 
is reduced; but as a consequence of fermentation the con- 
tents of the stomach become charged with organic acids, 
and are exceedingly acrid. Such cases are accompanied by 
pain in the epigastrium, distressing pyrosis, loss of appetite, 
and frequent vomiting. The stomach is distended, and 
succussion sounds are distinctly audible, painful sensations 
declare themselves soon after eating, but are usually less 
intense than the pain that is experienced in consequence of 
excessive secretion of hydro- chloric acid. There is progres- 
sive loss of flesh, and the skin acquires a cachectic hue that 
sometimes suggests the idea of cancer of the stomach. In 
certain cases there is regurgitation of bile into the stomach, 
which hinders gastric digestion and adds to the discomfort 
of the patient. 

It is evident that an accurate determination of these dif- 
ferent forms of dyspepsia can only be effected by the aid of 
chemical analysis. The presence or absence of free hydro- 
chloric acid can be readily determined by the ordinary color 
tests, but these are insufficient for an accurate diagnosis, 
which can only be established by a quantitative analysis. 
The prognosis depends largely upon the intensity of the 
symptoms and upon their duration. Mild and recent cases 
of a simple type usually recover, but dilatation of the stom- 
ach and the excessive secretion of hydro-chloric acid are less 
favorable symptoms. In the severer forms of hyper-secre- 
tion there is reason to fear the establishment of actual in- 
flammation, ulceration, or malignant disease. 

The indications for treatment are three-fold. (1) To re- 
lieve pain, (2) to correct nervo-muscular disorder, and (3) to 
rectify the quality of the secretions. 



262 nervous dyspepsia. [March-June, 

(1). Sensations of weight and distension may be fre- 
quently relieved by the administration of milk, small quan- 
tities of food, or water containing bicarbonate of sodium. 
When, however, pain assumes the character of intense neu- 
ralgia, hypodermic injections of morphine and atropia 
become necessary. Moderate degrees of pain may be relieved 
by the administration of Hoffmann's anodyne, cannabis indica, 
cocaine, hyoscyamus, and the saturated aqueous solution of 
chloroform. Of these remedies Hoffmann's anodyne is inferior 
to chloroform. Cocaine should be used with great caution, in 
doses not exceeding half a grain. The extract of cannabis 
indica may be used in the same proportions. In many in- 
stances great relief is obtained from copious draughts of hot 
water ; the methods of hydropathy are very serviceable in 
building up the general nervous system and in overcoming 
the neurasthenia that accompanies the disease. Cold sponge 
baths, shower baths followed by active friction of the skin, 
and frequent exercise in the open air, are essential elements 
in the treatment of nervous disorder. 

(2). Inefficient muscular contraction in the walls of the 
gastro-intestinal canal requires the use of nux vomica, ipecac, 
massage, electricity, injections of hot water, and stimulant 
laxatives. Nux vomica should be given in doses of five to 
ten drops of the tincture, a quarter of a grain of the extract, 
or a half a grain of the powdered nut, shortly after eating. 
Ipecac is especially useful when there is tympanitic disten- 
sion of the abdomen after meals ; it should be given in doses 
of one- tenth of a grain, and it may be associated with nux 
vomica, and with other gastro-intestinal stimulants, as in the 
well-known pill recommended by Fothergill, which may bo 
modified thus : 



1893.] BY H. M. LYMAN, M. D. 263 

I& Pulv. Ipecac gr. ^ 

Ext. Nuc. Vom gr. *4 

Pulv. Piper. Nig gr. j 

Ext. Gentian gr. j 

M 

Sig. One such pill after each meal. 

Aloin in sufficient doses may be added when there is con- 
stipation, and an occasional dose of blue mass and colocynth 
affords great relief. 

(3) Chemical rectification of the secretions requires, when 
there is excessive production of hydro-chloric acid, absti- 
nence from alcoholic drinks and highly seasoned food. Mas- 
tication must be slowly and thoroughly performed. Milk 
diet is often very successful. When the excess of hydro- 
chloric acid is present during the period of digestion alone, 
bicarbonate of sodium may be given in doses of five to 
twenty grains about three hours after each meal, at the time 
when pain begins to manifest itself. When, however, the 
gastric contents are continually charged with an excess of 
hydro-chloric acid, it becomes necessary to give the bicar- 
bonate of sodium to the amount of four or six drachms per 
diem. Vichy water, lime water, calcined magnesia, and 
Murray's fluid magnesia may be used for this purpose. 
When there is evident dilatation of the stomach with stag- 
nation of its contents, the stomach pump or the gastric sound 
should be employed, in order to remove the irritating li- 
quids. In default of such apparatus great relief can be ob- 
tained from an emetic of lobelia. Starchy and saccharine 
food should not be eaten: the patient should be nourished 
with milk, eggs, peptonized meat powders, and other nitro- 
genous articles of diet. 



264 nervous dyspepsia. [March-June, 

When there is adeficiency of hydro-chloric acid in the gas- 
tric juice, without dilatation or stagnation, hydro-chloric acid 
should be given after each meal; ten or fifteen drops of the 
dilute acid may be given in a glass of hot water after eating. 
The other mineral acids produce a similar good result. The 
extensive popularity of Horsford's Acid Phosphate is largely 
due to the action of its acid constituent. It must be under- 
stood, however, that the administration of acids is merely 
palliative, and not curative of dyspepsia. The same thing 
is true of pepsin and other digestive ferments. The disease 
oan only be overcome by the removal of its cause, that is, by 
the correction of the nervous disorder upon which it is de- 
pendent. In many instances great benefit is obtained from 
the long continued administration of small doses of the alka- 
line salts with gastric tonics before each meal. The ordinary 
neutralizing cordial, or the compound syrup of rhubarb and 
potassium, may be thus employed with great advantage. 

Dilatation of the stomach and excessive acidity of its con- 
tents, by reason of fermentation and the presence of organic 
acids, must be combatted by daily irrigation of the stomach, 
and by the administration of salol, salicylic acid, boric acid, 
or beta-naphtol. Electricity, massage, and hydrotherapy 
are also indicated in this class of cases. Change of air, 
long vacations among the mountains, and sea-bathing are 
often more effectual than the most elaborate medication. 



1893.] 265 



TRANSLATORS. 



ITALIAN. 
H. M. BANNISTER, M. D., HAMPTON, CONN. 

GERMAN. 

G. J. Kaumheimer, M. D., Milwaukee, Wis. 
H. M. Bannister, M. D., Hampton, Conn. 
Jos. Kahn, M. U., Milwaukee, Wis. 

DUTCH. 
William Sweemer, M. D., Milwaukee, Wis. 

FRENCH. 
J. G. Kiernan, M. D., Chicago, III. 

SPANISH. 
H. M. Brown, M. D., Milwaukee, Wis. 

SWEDISH, DANISH AND NORWEGIAN. 
Haldor Sneve, M. D., Minneapolis, Minn. 



266 neurological. [March-June, 



NEUROLOGICAL. 



ANATOMY AND PHYSIOLOGY. 



The Pituitary Gland. — Vassale and Sacchi, (Bev. Speri- 
mentale XVIII, III and IV, Dec. 1892,) publish the account 
of their experimental investigation in regard to the effects 
of the destruction of the pituitary body from which they de- 
duce the following conclusions: (1.) By our method of 
operating it is practicable to destroy, in the cat and dog, the 
pituitary gland with ease and precision. (2.) The complete 
destruction of the pituitary gland is fatal in the cat and dog,, 
independent of all operative complications. (3.) Partial 
destruction of the hypophysis is compatible with continua- 
tion of life for a long period in these animals, but with the 
typical symptoms of functional insufficiency of the gland. We- 
are not able in the present state of our researches to decide 
whether these phenomena of insufficiency may not, at a period 
more or less remote from the operation, give rise to a genu- 
ine fatal cachexia; or whether, on the other hand, they may 
not diminish and disappear so that the injured gland reas- 
sumes its functions in consequence of a process of partial re- 
generation, of which we have been able to observe evidences 
in one of our cases, (exp. 26). (4.) Increase of the chromo- 
phile cells in the pituitary gland is evidence of a degenera- 
tive process, rather than of a compensatory functional pro- 
cess of the same. (5.) Although the symptom-complex 
that follows complete destruction of the pituitary gland offers 
analogies to that which follows extirpation of the thyroid 
gland, we are unable, for the reasons given, to admit that 
the functional relations between these two bodies are such 
that one may, as Rogowitsch claims, be a substitute for the 
other in the needs of the animal economy. (6.) As regards 
its functions, the hypophysis belongs to the class of glands, 
destruction of which gives rise to the formation and 
accumulation within the organism of special toxic substances. 

H. M. BANNISTER. 



1893.] ANATOMY AND PHYSIOLOGY. 267 

The Finer Structure of the Spinal Cord in Man. — G. 
Mingazzini, ( Revista &perimeniale } XVIII, III and IV.) reports 
the results of the examination of over one thousand sections 
of the spinal cord in a case of amyotrophic lateral 
sclerosis, prepared according to the newer method of Golgi, 
which he discusses in comparison with the data previously 
obtained. The atrophy of the muscles in the patient, two 
months before death, involved more or less completely the 
arms, legs, back and face, and to a considerable extent those 
of the neck. The abdominal muscles and diaphragm were 
uninvolved and the sphincters functioned normally. The 
knee reflex was exaggerated, foot clonus present, cutaneous 
reflexes normal, there was exaggerated fibrillary excitability 
in the muscles that were intact. Pupillary reactions 
normal, special senses generally intact except hearing 
which was slightly impaired. Speech slightly impaired as 
to the pronunciation of guttural and dental sounds, degluti- 
tion difficult. Temperature slightly elevated, pulse 96, 
small. Examination of sections of the lower lumbar cord, 
revealed complete degeneration on both sides of a triangular 
space corresponding to the crossed pyramidal bundles, while 
the other regions were intact. In the middle and upper 
portions of the lumbar regions, the same tract was involved 
and the anterior horns were in part affected, many of their 
cells lacking, others without their prolongations, and still 
others shrunken. With carmine coloring they were of a 
uniform clear rosy tint, the nucleus undistinguishable. 
The nervous network of the gray substance, as compared 
with the normal condition seemed rather less rich in the 
fibres that ordinarily are found around the antero-lateral 
group of the cells of the anterior horn. In the dorsal 
segment of the cord, the same degeneration o f the 
pyramidal bundles was observed; the cells of Clark's 
columns and those of the posterior horns and the posterior 
root fibres were intact, while the anterior horns were notably 
and uniformly diminished in sections on both sides. In the 
anteriors horns the nervous network was apparently destroyed, 
the cells reduced to a very few, and those remaining 
reduced in size and with undistinguishable nuclei ; the 
anterior root fibres partially atrophied. In the cervical 
cord the same degeneration of the pyramidal fibres was 
observed. In the middle of the fundamental fibres of the 
anterior and the lateral columns there were vacant spaces 
corresponding to those occupied by the anterior radicular 



268 neurological. [March-June, 

fibres ; these bundles showed in some points an incipient 
but verv limited rarefaction. The size of the anterior horns 
was very much reduced and all the cells in the median, 
ventro-lateral, and postero-lateral groups had disappeared. 
In the whole field of the anterior horn (except in its median 
portion) and also in the lateral horn, the fibres of the 
nervous network were completely gone, so that this part 
appeared structureless ; only short fibres interwoven into a 
very loose network occupied the median portion of the 
anterior horn. Some fibres of the anterior commissure had 
disappeared, and comparing this commissure with that of 
the normal adult at the same altitude, it was observed that 
the fibres that bend ventrally along the median margin of 
the anterior horn, are preserved only in part. Nevertheless 
it was possible to distinguish fairly well two orders of fibres; 
the ones forming a very minute fascicle (ventral portion) 
bending toward the anterior horn and there becoming lost, 
or penetrating the fundamental bundle ; the others forming 
a thicker bundle (dorsal portion) turning dorsally and in 
some preparations distinctly visible in their continuation 
with fasciculi belonging to the median bundle of the 
posterior radicular fibres. From the bundles appertaining 
to the remainder of the lateral column were seen to proceed 
a compact fascicle of fibres, which, traversing the clear field 
of the base of the anterior horn, continued in the direction 
of the fibres of the anterior commissure. The course of the 
posterior radicular fibres could be followed with sufficient 
exactness, the lateral bundles could be seen to lose themselves 
in the network of fibres behind the anterior portion of the 
gelatinous substance; from this network proceed very 
minute fibres which thinning out pass toward the base or 
toward the center of the anterior horn where they were 
lost to view. Both the network and the fine fibres originating 
from it can be traced across the median bundle of the 
posterior root fibres, which pass obliquely outward in a 
lateral direction and there thinning out lose themselves, 
like the others, in the base of the anterior horn. In some 
well stained sections the terminal ramifications could be 
seen pushing further toward the lateral part of the cornua. 
In some sections it was observed that the more ventral fibres 
of the median bundles bend inward and pass on with the 
more dorsal fibres of the anterior commissure. In the 
discussion of the observations above described the author 
reviews the literature of the theories of the connection 



1893.] ANATOMY AND PHYSIOLOGY. 269 

between the anterior roots and the pyramidal tracts, that is 
the connections of the cerebro-spinal and spino-muscular 
systems. Since the discovery by Golgi of the presence of 
collateral fibres from the anterior and lateral columns to the 
network in the gray substance and of fibres from the cells 
of the anterior horns to the same, it has been admitted 
hypothetically that the connection between the great 
multipolar cells of the anterior cornuaand the pyramidal 
fibres is effected by these. Mingazzini believes that his 
observations, while not affording an exact anatomical 
demonstration of this connection, yet go far to show in 
what portion of the nervous network it is effected. The 
gradual disappearance from below upward of the nervous 
network and the cells of the anterior horns, together with 
the complete degeneration of the pyramidal columns, 
indicate that the same morbid process must affect them 
both, and presumably the columns first. The network of 
the anterior horn cannot, according to the data of histology, 
be considered as formed by the terminal ramifications of 
the collateral fibres of the pyramidal columns, and since 
these ramifications appertain to the distal portion of the 
cerebro-spinal system, while the cells of the anterior horns 
belong to the spino-muscular, the affirmation is justified 
that the nervous network of the anterior (and lateral) 
cornua represents almost in total (except in its more central 
portion) the intermediary system between these two systems. 
The view of Gowers that the degenerative process 
simultaneously affects both in amyotrophic lateral sclerosis 
is not supported by the fact of the progressive disappearance 
of the cells while the lateral columns are degenerated 
throughout, as is here pointed out. The functions of the 
different groups of the cells of the anterior cornua, especially 
the postero-lateral group are discussed at length and the 
literature of the subject is gone over quite fully. 
Mingazzini adopts in the main the view expressed by 
Kolliker and Ramon y Cajal, who explain spinal reflex 
action by the intervention of the antero-posterior or 
sensori-motor collateral fibres discovered by them, and also 
adopts with slight modification the schema of Waldeyer, by 
which this mechanism is explained. The bearings of his 
investigations on the question of the structure of the anterior 
commissure is also discussed and his conclusions in regard 
to the whole are summed up as follows : (1.) That the 
nervous network (intreccia) of the anterior horn (except in 



270 neurological. [March-June, 

its median portion) is formed almost entirely from the 
terminal fibrils (collaterals from the pyramidal bundles,) 
that maintain in relation the cerebro-spinal with the 
musculo-spinal segments of the pyramidal route. (2.) 
That all the groups of cells of the anterior (and lateral) horn 
have motor functions; but the medial and ventro-lateral 
groups are in direct relation only with the collaterals from 
the pyramidal fibres, while the postero-lateral group is in 
relation not only with these, but also with the terminal 
extremities of the sensory collaterals from the posterior 
radicular fibres which push with their terminal extremities 
as far as the base of the anterior horn. (3.) That the 
anterior commissure is formed of two parts ; a dorsal portion 
formed by the crossing of a part of the posterior radicular 
fibres, and a ventral portion formed in part, at least, by the 
prolongations of the cells of the anterior horns and of the 
anterior radicular fibres. 

H. M. BANNISTER. 

The Function of the Thyroid Gland. — Dr. J. L. Gibson 
read a paper upon this subject before the Third Intercolonial 
Medical Congress of Australia. From experiments upon 
dogs he concludes that the thyroid possesses no blood-form- 
ing properties, but was unable to disprove its alleged 
function as compensatory to the spleen. Dogs living long 
enough after excision of the thyroid become ansemic for the 
reason that the absence of this gland has a serious effect 
upon the nervous system. It probably secretes some material 
necessary for the nourishment of the nervous system. Dr. 
Gibson transplanted thyroid of a lamb into abdomen of a 
child of six years in whom he considered the gland to be 
functionally absent. Improvement of mental state noticed 
day after operation. July 27 — nine days after grafting, noted 
he looked much brighter. July 31 — CEdema much less; 
extremeties warm; skin had lost former glazed appearance. 
Aug. 2 — Mother considers him thinner than ever before. 
Aug. 5 — Makes sounds as though trying to talk. Nov. 12 
— OEdema disappeared, although feet, lips and hands still 
rather thick. Skin natural and all symptoms improved. 
May, '93 — Improvement having ceased second grafting was 
made in abdomen. Sept. 4 — Appears now like a well 
nourished child between two and three years of age. 
Myxcedema cured and cretinism lessened. {The Lancet, 
Jan. 14.) 



1893.] ANATOMY AND PHYSIOLOGY. 271 

Position and the Cerebral Functions. — Dr. J. Sicard 
(Gaz. des Hop. Dec. 22, 1892) starting from the premise that 
continuity of blood irrigation is a necessity for regular work 
by the cerebral cells, analyzes the influence of horizontal and 
vertical positions on cerebral functions. The horizontal 
position favors the mechanical blood afflux toward the 
brain while the vertical has the opposite effect. He points 
out that the pressure exercised on the vessels at the base by 
the cerebral mass varies with the position. Vertigo, he points 
out, is the result of circulatory modifications in the interior 
of the brain which may result either from anaemia or 
hyperemia. These two types are oppositely affected by 
position; vertically improves one while the reverse occurs in 
the vertical position with the other. He points out that on 
rising melancholies are often worse. The reverse is the 
case with mania. j. G . kiernan. 

Suprarenal Capsules and Muscular Work. — Dr. J. E. 
Abelons and P. Langlois state (Arch, de Phys., July, 1892) 
that the toxicity of the blood of guinea-pigs deprived of the 
supra-renal bodies indicates that there accumulates in the 
organism under such circumstances one or more toxic 
substances. These act particularly on the motor nerve ends 
in the muscles, Injection of an aqueous extract of the 
suprarenal bodies seems to modify favorably the symptoms 
produced by the absence of that body. In their opinion 
the suprarenal bodies fabricate substances which neutralize 
or destroy poisons fabricated in the course of muscular 

WOrK. j G KIERNAN. 

Fundamental Colors. — Dr. Chauveau concludes (Mercredi 
Med., Dec. 7, 1892) that green by direct demonstration and 
red and violet by circumstantial evidence seem to have the 
right to the designation of fundamental colors attributed to 
them by Young. In the nerve centres for the perception of 
these colors are cells distinct or endowed with special 
sensibilities to red, green or violet. These are not equally 
or simultaneously roused into activity. Green is the first 
to awaken. A man sleeping near a window permitting 
sunlight to reach both eyes about equally well, when his 
eyelids are raised, see white objects in a fugitive but vivid 
green illumination. The normal eye hence has the power of 
analyzing white light and decomposing it into its fundament- 
al COlorS. J. G. KIERNAN. 



272 neurological. [March- June,. 

Literature and Primeval Man — Letourneau, (Rev. 
Mens, de VEcole del' Anthropologic de Paris, Nov., 1892.) 
states that man of every race in every age has found need 
of aesthetic expression; this being an essential of human 
nature. This need, the primordial factor of literature r 
clothes itself progressively in diverse forms. Primitive 
literature, everywhere the same, has probably preceded the 
invention of articulate language since the anthropoid, like 
other animals, possess a vocal language constituted by 
modulated cries resultant on simple reflex actions. Song has 
constituted everywhere the principal element of primitive 
aesthetics. Mimicry, which everywhere accompanies song, is 
another. Literary aesthetics of all primitive peoples are 
founded in an indissoluble trinity,mimicry, music and poetry. 
This last at first is a simple accessory of song. From the 
liking of primitive man for vocal music with its rhythmic 
measured sound is born metre which is perfected co-relatively 
with cerebral development and instrumental music parallel 
develops. With the development of individual property, of 
marriage, of social relations, are born ideas and new 
sentiment, which, developing, strive to secure expression and 
new poetic forms are engendered and also successively new 
literary forms. Literature very narrowly depends on the social 
state. It is both an effect and, by its expansion, a cause. 
In epochs of moral involution (or degeneracy) literature 
loses its nobility, force and aesthetic beauty. A sign of 
decadence literature is abuse of descriptive power. It 
evinces exhaustion of ideation or interdiction of its 
expression. 

J. G. KIERNAN. 



PATHOLOGY AND SYMPTOMATOLOGY. 

Tumor of the Brain. — The following cases came under 
the care of Dr. Simpson: Case 1. — Female, age 66. For 
four years suffered from increasing paresis of both legs ; 
increase in tendon reflex ; deaf in right ear for same length 
of time, partially deaf in left. Double optic neuritis. Had 
severe headaches, nausea and vomiting and attacks of 
dizziness. Sank into comatose condition some days before 
death. Post mortem showed large tumor occupying upper 
and posterior portion of temporo-sphenoidal convolutions 
from fissure of Sylvius to sulcus between second and third 
convolutions. Carcinomatous nature ; sprang from dura 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 273 

mater of temporal bone. Case 2. — Man, aged 18. Admitted 
to hospital Nov. 2, 1891, died June 21, 1892. Patient was 
in hospital eight months before and had pain and swelling 
in right hip for three months and pain in right knee. On 
admission, fullness over right hip joint, great pain on 
attempted movement. Thigh was kept rigid and there was 
tenderness over the anterior part. Leg and thigh put in 
extension apparatus. March 2nd, condition as follows : 
" Tubular breathing over upper part of front of left lung 
and dullness of the left base behind ; caries of the fifth right 
rib ; abscesses over front of right femur, left elbow joint and 
over third right rib." May 10th, complete left facial palsy, 
diplopia on looking to left, paralysis of left external rectus, 
double optic neuritis ; urine contained one fourth albumen. 
Frequent headaches. Anaesthesia of cornea and left side of 
face. June 19th, unable to retain anv food. Post-mortem 
showed tumor about size of filbert in left side of pons 
Varolii, pressing on floor of left ventricle especially on roots 
of third, fourth, fifth, sixth and seventh nerves. On being 
cut into was found to be commencing to caseate in center. 
(Lancet, March 25, 1892.) 

B. M. CAPLES. 

Case of Cystic Tumor of the Brain. — At the meeting of 
the N. Y. Neurological Society Jan. 3, Dr. Leo Steigler 
showed a woman, twenty-five years of age. Married six 
months previous to appearance of symptoms, October 1891. 
No hereditary taint, history of syphilis or traumatism. Was 
suddenly seized with twitchings of thumb and forefinger of 
right hand. Twitchings led in a few moments to loss of 
consciousness, cyanosis, frothing at mouth, and tonic and 
clonic convulsions. Similar attack occurred seven weeks 
later followed by a number of others. No trace of head- 
ache, nausea, giddiness, etc., still suspicion of a localized 
cerebral lesion was aroused. Operated upon by Dr. Gerster, 
June, 1892. Dura bulged slightly into opening and an area 
the size of half a dollar, corresponding with centre for 
movement of fingers, showed a yellowish tinge. No apparent 
change in cortex of brain, but upon incision an ounce of 
yellow serous fluid escaped. Walls of cyst were smooth and 
owing to the delicacy of the membrane could not be 
removed. Small layer of gray matter excised. By 
November patient had lost sensation of position in third 
and fourth fingers, but strength of hand and arm had 



274 neurological. [March-June, 

increased. December 10, considerable twitching in arm 
and face. Patient had been kept on daily doses of 15 to 30 
grains potassium bromide since operation. Dr. Steigler 
thought glioma cause of trouble and there was reason to 
fear further growth of gliamatous material presumably left 
in walls of cyst. Advised operations removing entire cyst. 
Dr. Starr doubted if removal of walls were possible ; 
furthermore, there was probably infiltration of brain 
substance. Out of 87 recorded operations for removal of 
brain tumors 46 per cent, ended in recovery. (New York 
Med. Jour., Jan. 28.) 

Apoplectiform Symptoms in Cerebral Tumors. — It is 
well known that cerebral tumors may simulate almost any 
other form of cerebral disease. Apoplectiform attacks are 
however, very rare and are usually the result of hemorrhages 
caused by the tumor. Kuttner reports two cases from 
Ewald's practice, which presented the clinical picture of 
an apoplexy during life and in which no trace of 
hemorrhage recent or remote could be found. In case 1, 
a man of 33, who survived the attack a month, a cystic 
glioma was found occupying almost the whole of the right 
occipital lobe. Case 2 was a woman of 38, who survived 13 
days. A metastatic carcinoma as large as a pigeon's egg, 
surrounded by an extensive area of softening was 
found in the left temporal lobe. This was secondary to a 
carcinoma of the right lung. Ladame has found such a 
course 11 times and in 10 cases softening had occurred 
around the tumor. The clinical diagnosis is usually 
impossible in such cases. — (Zur Casuistik der Himtumoren, 
Dr. Kuttner, Bed. Klin. Wochensch., No. 27, 1892.) 

G. J. KAUMHEIMEB. 



Symptomatology op Tumors op the Corpora Quadri- 
gemina. — The symptoms which are of diagnostic value in 
tumors of the corpora quadrigemina are the ocular paralysis 
and the disturbances of equlibrium. The ocular palsies are 
generally due to lesion of the nuclei and are consequently 
dissociated. Paralysis of the abducens seems to be of quite 
constant occurrence, usually appears early and may remain 
unilateral. The oculomotor paralysis is usually bilateral, 
although it may not be sy metrical. The abducens 
paralysis is usually due to pressure upon the trunk of the 
nerve. The disturbances of equilibrium may assume the 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 275 

form of cerebellar or of ordinary ataxia and may be 
accompanied by severe vertigo, although it is of equal 
diagnostic value with the ocular palsies. Neither of these 
are "direct" symptoms, as they are absent in cases of 
softening. The ataxia is probably due to pressure upon the 
cerebellar peduncle. Most modern authors agree that there 
are no direct symptoms indicating lesion of these bodies. 
(Prof. Lichtheim, Deutsch. Med. Wochensch., No. 46, 1892.) 

G. J. KADMHEIMER. 



Cerebellar Tumors and the Knee-Jerk. — Dr. Handford 
reports in Brain a case of some interest. The patient was a 
lad of 16 whose first symptom was apparently causeless 
vomiting. He subsequently suffered from headache and 
dizziness, with difficulty and unsteadiness in walking. 
When he came under observation he had an ataxic gait and 
was subject to occasional fits, apparently of opisthotonic 
character. He also was found to have optic neuritis in both 
eyes, and he subsequently had some weakness of the ocular 
muscles and nystagmus. Knee-jerks absent on both sides ; 
ankle clonus present on both sides. Became progressively 
worse. Died six months after onset of symptoms. Tumor 
found in middle lobe of cerebellum. Dr. Handford refers 
especially to the absence of the knee-jerks. He states the 
different views which are held with reference to the 
production of the so-called tendon reaction and especially 
refers to the well-known views of Dr. Hughlings Jackson 
and Dr. Charlton Bastian with regard to the cerebellar 
influence. Dr. Bastian related the facts of several cases of 
total transverse lesion of the spinal cord, in which, in spite 
of marked sclerosis in the pyramidal tracts found post 
mortem, the knee-jerks remained absent, a condition which 
was referred to the cutting off of the cerebellar influence — 
the influence which, according to Dr. Jackson's views, is 
responsible for the maintenance of muscular tone and the 
presence of tendon reactions. Dr. Handford regards his 
case as having almost the value of an experiment in show- 
ing the connection of the knee-jerks and the cerebellum, 
and says further that, according to widely accepted views, 
the pressure of the tumor on the medulla should have 
produced descending sclerosis of the crossed pyramidal 
tract and exaggerated knee-jerks. Dr. Gowers states that in 
many cases of cerebellar tumor the knee-jerk cannot be 
obtained, and that in the same case it is at times present, 



276 neurological. [March-June, 

at other times cannot be elicited. This fact may give a 
certain amount of support to Dr. Jackson's theory. The 
facts of Dr. Handford's case suggest this variability in 
tendon reactions, as on one occasion ankle clonus was 
elicited. This is a curious and interesting fact, for it must 
be very rare to find ankle clonus present, (a phenomenon 
which can usually only be evoked in an exaggerated state 
of the conditions on which the knee-jerk is supposed to 
depend) whilst the knee-jerk itself remains absent. The 
case is one of unusual interest and suggestiveness, but 
observers will probably not agree as to the interpretation of 
its phenomena. (Lancet, Feb. 11, 1893.) 

B. M. CAPLES. 

The Otic Sign in Cerebral Diseases. — Gelle {Ann. 
des maladies de Voreille et du larynx, May, 1892.) considers 
that clinical observation shows the importance of recognizing 
the presence or disappearance of this functional sign, 
known as the binaural reflex of accommodation, whether 
there is deafnesss or not in diseases of the middle ear, in 
those of the internal ear, or in intracranial diseases, which 
produce vertigo, tinnitus aurium, deafness, facial paralysis, 
etc. The absence of transition of the synergetic irritation 
in cases of sclerosis is a mechanical fact, which explains the 
simultaneous loss of the effect of centripetal impressions of 
the tuning fork on the hearing, added to other signs of the 
presence of otitis media. When a haemorrhage or an 
inflammation has seriously altered the labyrinthine contents, 
the reflex of synergetic accommodation is equally wanting. 
It is gone from both sides, and coincides with a limited 
deafness and with various disturbances of equilibrium and 
of the senses, which constitute the syndrome of labyrinthine 
lesions. (N. Y. Med. Jour., Jan. 21, 1893.) 



The So-called Bezold Variety of Mastoiditis ; Opening 
of the Mastoid ; Craniotomy ; Death ; Autopsy ; Abscesses 
in the Temporal Lobe and Cerebellum ; Sinus Thrombosis 
on the Other Side. — Knapp (Arch, of Otol., XXI, 3.) reports a 
case occurring in a young woman who suffered from repeated 
attacks of naso-pharyngeal catarrh, extending into both 
ears, for about a year. The left ear recovered. The fourth 
and later attacks showed implication of the right mastoid, 
with marked meningitic irritation. The upper part of the 
sternocleido-mastoid muscle became red, swollen, and 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 277 

painful. Ten days after her confinement a deep incision 
was made into the swollen head of the muscle, liberating a 
quantity of pus. The relief being only temporary, the 
mastoid was opened from base to tip, and the wound kept 
open by a perforated silver tube. The patient felt relieved 
and comparatively well for two weeks. Then symptoms of 
cerebral irritation returned and lasted until her death, 
three months later. These symptoms were persistent 
headache, nausea, occasional vomiting, dizziness, stupor, 
impairment of speech, loss of appetite and constipation. 
The pulse at first varied from 70 to 88, later sank to 60. 
The temperature varied between 98.4° and 100°. There 
were no convulsions, delirium, chills, or abnormal sensation. 
The ear never gave her any more trouble, and there was 
never any discharge from the canal, though the drumhead 
was red and bulging. Two months before death a swelling 
was noticed below the head of tho sterno-mastoid muscle on 
the other side. The left ear remained healthy. Optic 
neuritis developed in both eyes during the last months of 
life. Craniotomy was done the day before she died. The 
opening in the mastoid was enlarged and extended into 
the cranial cavity. The dura mater and lateral sinus were 
found healthy. Then the wound was extended into the 
tympanic attic, but no pus being found here and the bone 
being thick and hard, the middle cranial fossa was opened 
through the squamous portion of the temporal, just above 
the auditory canal. There was no extradural suppuration, 
and the dura mater and superficial layers of the brain were 
healthy. She lived about an hour after the operation. 
The autopsy showed : 1. Perforation in the medial bony 
surface of the tip of the mastoid. 2. The upper part of 
the drum filled with granulation tissue. 3. The right 
lateral sinus healthy. 4. The dura healthy throughout. 
5. The pia mater of right temporal lobe and right cerebellar 
hemisphere milky and its small veins filled with pus. 6. 
The sinuses in the median line, those adjacent to the median 
line on the right side, and all the sinuses on the left side, 
and the left internal jugular vein, were filled with pus. 7. 
In the right temporal lobe an abscess as large as a walnut, 
and in the right cerebellar hemisphere another of the sam^ 
size. 8. Microscopic specimens and cultivations from the 
cranial abscesses showed small bacilli and the staphylococus 
aureus. (JV. F. Med. Jour., Jan. 21, 1893) 



278 , neurological. [March-June, 

Glycosuria following Apoplexy. — In a paper published 
in Prag. Med. Wochensch., (Nos. 31 to 33, 1892,) v. Jaksch 
states that although transitory glycosuria has been reported 
after apoplexy, he has not been able to find a case among 
50 cases of fresh apoplexies within the two years preceding 
and seems to doubt the causative relationship. This has 
called out several replies. Dr. Emil Schulz (Ueber d. 
Vorkommen transitorischer Glycosurie nach apoplectischem Insult, 
Prag. Med. Wochensch., No. 50, 1892) relates a case in which 
glycosuria occurred after two separate apoplectic attacks, 
lasting six days after the first and three days after the 
second attack. From a study of the accessible literature, S. 
concludes that glycosuria results only when the fourth 
ventricle is involved by the lesion. Dr. M. Loeb {Glycosurie bei 
Gehirnapoplexie, ibid) also gives two instances from his own 
practice and a number from literature and presents the follow- 
ing conclusions : 1. In some, mostly fatal cases of cerebral 
apoplexy (cerebral and meningeal haemorrhage) sugar can 
be found in the urine. 2. The excretion of sugar rarely 
continues longer than 12 to 24 hours and usually takes 
place only during the coma. 3. The percentage of sugar 
varies from one-fifth per cent, to several per cent. 4. 
Albuminuria, which always lasts longer than the glycosuria, 
is frequently present. 

G. J. KAUMHEIMER. 



A Case of Diabetic Hemiplegia and Aphasia. — The 
connection between diabetes and nervous symptoms has 
long been known. On the one hand, diabetes is often of 
nervous origin. Tumors, cysticerci or sclerotic processes in 
the brain may cause it. It has been observed in tabes, 
following apoplectic and epileptic attacks and after 
traumatism. On the other hand, nervous symptoms are 
not rare in diabetes not of nervous origin. Various 
distubances of sensation, anaesthesia, parsesthesia, neuralgia, 
and neuritis with impairment of both motor and sensory 
functions have been found as well as psychical depression 
and general weakness. Absence of the patellar reflex has been 
noticed very frequently, and has been variously attributed 
to neuritis and to functional disturbances of toxic origin. 
In the motor sphere we may find symptoms of irritation, 
epileptiform convulsions and paralysis of single muscles 
and members, of central origin. Hemiplegia and apoplecti- 
form attacks have also been observed, though less often. 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 279 

The causes of these latter are various. Occasionally there is 
simply a coincidence, and at other times the apoplexy may 
be due to deceased arteries caused by the diabetes or to the 
influence of the toxic substances circulating in the blood. 
The author reports the case of a heretofore healthy laborer 
who had worked in a chemical factory and handled a great 
deal of aniline dye. Six weeks before admission to the 
hospital he complained of frequent nausea and weakness, in 
spite of an inordinate appetite and great thirst. Polyuria 
and emaciation was also noticed at this time. Three weeks 
later he noticed weakness, pain and stiffness in the right 
arm and leg. This improved somewhat later. Two weeks 
before admission, he had numerous rightsided spasms, with 
a great flow of saliva but no loss of consciousness. It was 
found that he had lost the power of speech. The palsy and 
aphasia showed some improvement in a few days but 
became worse two days before he entered the hospital. Here 
it was found that he could answer simple questions although 
part of his speech was unintelligible and he could not repeat 
difficult words. He could write correctly and read by 
spelling out the words. The eyes were normal. The 
muscles supplied by the middle and lower segments of the 
facial nerves were paretic. The patellar reflex was reduced 
on the right side. The right arm and leg were paretic. No 
Romberg symptom. A few days later he had very frequent 
convulsions, beginning with deep and noisy respiration, 
followed by a short period of tonic spasm in the territory of 
the middle and lower segments of the right facial nerve, 
then a longer period of clonic spasm in the same region 
with spasm of the muscles of the neck and twitching of the 
right arm. Toward the end, a profuse flow of saliva set in, 
which continued after the cessation of the spasm. The 
attacks lasted about two minutes and were not attended by 
loss of consciousness. The condition became steadily worse 
and death occurred on the fifth day in hospital. Autopsy 
showed intense acetonaemia, cerebral hyperaemia and 
parenchymatous hepatitis. The microscopic examination 
of the brain showed only an intense engorgement of the 
cerebral vessels, the nervous elements being normal. As 
the urine contained a large quantity of acetone and other 
abnormal constituents, the author considers, in the absence 
of organic change, that the hemiplegia was of toxic origin. 
(Dr. Emil Redlich, Wien. Med. Wochenschr., No. 37-40, 1892.) 

G. J. KAUMHEIMER. 



280 neurological. [March-June, 

Hemiplegia Following Diphtheria. — A case of Dr. 
Seiferts is reported in the British Med. Journal, in which on 
the 10th day from commencement of a severe attack of 
diphtheria, paralysis of soft palate came on ; cardiac dullness 
enlarged towards right ; ventricular systole irregular, feeble 
and intermittent. Next day increased cardiac debility, 
with symptoms of collapse occurred. Following night 
patient suddenly awoke with a cry, stared around but could 
neither speak nor move her right limbs ; lower part of right 
side of face also paralyzed, tongue deviated to right; no 
•convulsions ; sensibility on hemiplegic side normal ; able to 
understand spoken language, but to all questions responded 
"Anne, Anne". For some weeks little change; speech 
normal at end of six months ; indications of partial degen- 
eration of pyramidal tracts. Sequence of events according 
to Seiferts — myocarditis, cardiac thrombosis, embolic occlu- 
sion of Sylvian artery. 

Case of Double Hemiplegia with Bulbar Symptoms. — 
Service of J. Hughiings Jackson, M. D. Patient, aged 52, 
suddenly became giddy while walking, also paralyzed on 
left side, and had difficulty in talking and swallowing. 
Five years before had similar attack with loss of power on 
right side. Onset of both attacks sudden. Nothing of 
importance in history with exception of an attack of gout 
ten years previous. Complete paralysis of palate but not of 
vocal cords ; movement of the box of larynx not affected ; 
no wasting of muscles nor fibrillary tremor. Plantar reflexes 
excessive but equal ; knee-jerks exaggerated ; slight ankle 
clonus obtained on right side; sphincters unaffected; sensi- 
bility normal. Ophthalmoscopic examination pointed to 
albuminuric retinitis. No aphasia or impairment of 
ability to read and write but great difficulty in articulation. 
Urine contained albumen. Patient very hysterical. Eigh- 
teen months after seizure suddenly lost consciousness and died 
in state of coma. Necropsy showed quantity of blood in 
subarachnoid space over pons, medulla and inferior surface 
of cerebellum, this coming from a rent in roof of fourth 
ventricle, also from corpus callosum. Haemorrhage appar- 
ently started in anterior part of left lateral ventricle where it 
had extensively ploughed up white matter and basal 
ganglia, also the pons. All vessels at base were atheroma- 
tous. Kidneys showed granular contraction, and left 
ventricle of heart was hypertrophied. After hardening, 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 281 

cord and medulla showed extensive degeneration of 
pyramidal tracts from crura downwards. Hypoglossal 
nuclei normal. Slight differences from the symptoms of 
bulbar paralysis enabled Dr. Hughlings Jackson to predict 
a double lesion higher than the bulb. In above case the 
important points in regard to diagnosis were the distinct 
history of two separate attacks of hemiplegia, absence of 
usual wasting of tongue and of the "squirming" movements 
present in bulbar paralysis, and absence of fibrillary 
twitching in other parts. The weakness of chest probably 
accounted for feebleness of voice, but difficulty in articula- 
tion resulted from paralysis of palate. Conditions present 
in this case explained by the hypothesis, "that bilateral 
movements habitually associated are represented in each 
half of the cerebrum." After first attack articulation was 
only temporarily interfered with because path on one side 
was preserved, but after second seizure peripheral mechan- 
ism of articulation was rendered inactive. Unfortunately 
the haemorrhage made it impossible to locate lesions, but 
Dr. Hughlings Jackson thinks that the double descending 
degeneration visible above level of medulla, and the healthy 
condition of cells of bulbar nuclei, prove the case to be one 
of double hemiplegia instead of bulbar paralysis. — [Lancet, 
Dec. 10.) 

Arterial Pressure in Hemiplegia. — Dr. Fere has studied 
sphygmographically {La Trib. Med., Feb. 2) arterial 
pressure in hemiplegia. There has been constant diminu- 
tion on the affected side. These phenomena are observed 
in hysteric hemiplegia also. He suggests this as a means 
of detecting simulation. 3m Gi K iehan. 

Functional Ophthalmoplegia with Paralysis and 
Implication op Cranial Nerves in Young Women. — 
Dr. Suckling [British Med. Journal, Mar.) records two cases 
of ophthalmoplegia with general motor weakness and other 
paralytic symptoms. Patients complain of heaviness and 
difficulty in raising limbs ; restricted movements of eyeball, 
nystagmus, there being ophthalmoplegia externa ; diplopia 
and squinting at times ; no aphasia, motor or sensory ; 
difficult mastication ; slight chorea in one ; no thoracic, 
abdominal, or urinary affection ; no mental peculiarity ; 
suffocative attacks in one, with probable paralysis of 
abductors of vocal cords. Recovery may take place or 



282 neurological. [March -June, 

patient may die from paralysis of abductors of vocal cords, 
or from some intercurrent disease as bronchitis or 
pneumonia. Dr. Suckling believes these cases and three 
similar ones of Dr. Bristowe prove that there is a functional 
disease chiefly affecting young women, which is characterized 
by ophthalmoplegia, with other motor symptoms, as, 
hemiplegia, general paralysis, dysphagia, dysarthria ; and 
that the affection is chronic and closely allied to exophthal- 
mic goitre. The affection is one of the motor nuclei in the 
iter and floor of fourth ventricle ; general paresis probably 
due to extension of disease into motor tracts ; nuclei of 
third, motor nuclei of fifth, nuclei of facial, spinal accessory, 
and hypoglossal nerves probably affected. 



Cerebral Syphilis and Its Relations to Nervous 
Diseases. — Tarnowski (Congress of Human Physicians, 1892) 
set up the following theses: 1. Anamnesis, sequelae of 
syphilis and the result of experimental therapeutics cannot 
be acknowledged as a scientific basis for the diagnosis of 
cerebral syphilis. 2. Syphilis is, at present, too commonly 
assumed as a cause of cerebral disease. 3. The diagnosis 
can only be made on the basis of the symptomatology 
peculiar to the disease. 4. The diagnosis is impossible 
without an accurate knowledge of nervous and mental 
diseases. 5. Tabes and progressive paralysis are never 
phenomena of syphilis. 6. The mercurial treatment of 
tabes and progressive paresis should be abandoned, even 
when antecedent syphilis has been proven. 7. Alcoholism 
and predisposition are the most important factors favoring 
the localization of syphilis in the brain. ( Wien. Med. 
Wochensch., No. 50, 1892.) 



G. J. KAUMHEIMER. 



Syphilitic Affections of the Nervous SYSTEM.-Abstract 
of Lettsomian Lectures delivered by Dr. J. S. Bristowe. 
The lecturer stated that syphilis must be considered as a 
specific infective disease due to the invasion and prolifera- 
tion of living organisms, and as having relationships with 
other specific infective diseases, especially small-pox, 
tuberculosis and cancer. Like the last two, syphilis is apt 
to assume an aggressive character after an indefinite period 
during which the poison is inactive. The lesions of 
syphilis are all irritative growths determined by the actual 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 283 

presence of the living organism. The difference in the 
specific proclivity to attack certain tissues,which distinguishes 
the secondary and tertiary stages, Dr. Bristowe attributes to 
changes in the relative sensibility of the soil due to the 
protective or modifying influence exerted upon the tissues 
during the former of these stages : and he holds further, 
that the distinctive features of inherited syphilis are due in 
different degrees to operation of the same cause, to difference 
of vulnerability of the foetal tissues as compared with those 
of the adult, and to interference with developmental 
changes which are going on in early life. Any infected 
tissue may convey germs of the disease to others. The 
consequences naturally following syphilitic arterial disease 
are derangement of nutrition and circulation in parts 
supplied by diseased vessels, with either softening or 
haemorrhage. Usually these lesions occur in limited districts. 
Dr. Bristowe related the histories of several cases illustrating 
this subject, which are of interest as they describe the 
character and consequences of advanced syphilitic arterial 
disease of large vessels, the lesions or symptoms referrable to 
the nervous centers being of secondary importance. ( The 
Lancet, Jan. 14.) 

Syphilis op the Nervous System. — Dr. Hoppe reports 
the case of a man who had contracted syphilis six years 
previously, seized with a rapidly oncoming hemiplegia with- 
out facial paralysis or disturbances of speech. This gradu- 
ally improved, two years later had pains in arms and hands, 
followed in a few days by paralysis of all extremities, 
sensory disturbances, and difficulty of swallowing; died 
three months later of pneumonia. Spinal cord was the 
seat of two different pathological lesions, one being a com- 
bined systemic disease affecting the pyramidal tracts whole 
length of cord and columns of Goll and to a less extent of 
Burdach in the cervical and dorsal regions. The columns 
of Clark and the cerebellar tract also involved. The second 
lesion was an acute softening affecting the lower cervical 
and upper dorsal cord. -The microscope gave chief evidence 
of the syphilitic nature of the process. Arteries and veins 
of cord diseased. He reports a second case in which the 
disease was situated in the pons, presenting during life the 
picture of bulbar paralysis. A rapid left hemiplegia with 
paralysis of both sixth nerves and paresis of lower 
face followed by paralysis of all extremities, both facial and 



284 neurological. [March-June, 

hypoglossal nerves, great dyspnoea and rapidity of pulse. 
Patient died in three days. The lesions affected both sides 
of pons, total on right and and partial on left, also involved 
both fillets. The paralysis of the cranial nerves was due to 
the lesion in their paths above their nuclei. These latter 
(except that of the sensory fifth) being intact. The basilar 
artery was completely obstructed and a structure resembling 
a gumma found in its wall. Patient contracted syphilis 
ten years previously. Had for some months before fatal 
illness suffered from intense and constant headache, 
generally in occipital region. (British Medical Journal, April 
1, 1892.) 

Syphilis and Osteoarthropathy Hypertrophiante 
Pneumique. — It has long been known that in the course of 
certain disease of the heart and lungs a deformity of the 
hands and feet occurs, consisting in enlargement and 
clubbing of the fingers and toes and flattening and bending 
of the nails. This has been confounded with akromegaly, 
but Marie has pointed out the differential diagnosis. H. 
Schmidt (Munch. Med. Wochenschr., No. 36, 1892) reports a 
case with a syphilitic history in which the enlargement of 
the terminal members disappeared after the use of iodides. 
(Deutsche Med. Wochenschr., No. 40, 1892.) 

G. J. KA.UMHEIMER. 

An Unusual Case of Cerebro-Spinal Meningitis. — W. 
Gilman Thompson, M. D., puts on record an interesting 
case of cerebro-spinal meningitis, occurring in a boy of 10 
years, who fell several feet, very soon became comatose in 
which condition he remained until death from exhaustion 
10 weeks later. Symptoms attributed to extensive lesions 
of meninges and of brain and cord ; no external evidences 
of contusion or fracture ; emaciation very great. In few 
weeks contraction of flexor muscles occurred and extension 
well nigh impossible ; risus sardonicus very pronounced ; 
mouth rigidly open ; temperature and pulse fluctuate 
greatly. Four weeks before death an eruption of dusky red 
maculae appeared ; four days before death left cornea 
became opaque and ruptured ; at intervals patient emitted 
peculiar cry resembling cri hydrocephalique. Autopsy — 
Lesions of special interest found in brain and cord ; 
calvarium thin ; no fracture ; dura mater much thickened 
and beneath it, forming a fluctuating mass on left side, 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 285 

over frontal and parietal lobes, were found two ounces of 
blood-stained serum and pus; brown-red pigmentation of 
dura over most of the surface ; pia congested and 
thickened especially on left side ; convolutions of left 
hemisphere infiltrated with brown-red pigment, and 
atrophied ; entire brain very soft ; weight 37 ounces. 
Microscopical examination — Cerebral cortex contains 
unusual number of nuclei and small round cells very 
abundant in certain areas of pia mater; cerebral vessels 
distended with blood ; cord meninges intensely congested ; 
cord extremely soft. Features of chief importance sudden- 
ness of invasion, with no evidence of traumatism, and no 
epidemic of cerebro-spinal meningitis in vicinity; long 
duration of case, despite the extraordinary emaciation ; 
lateness of appearance of eruption : extreme degree of flexion 
and rigidity of joints ; irregularity and extensive range of 
temperature. — (Med. Record.) 



Traumatic Lesions of the Spinal Cord. — Dr. Preston 
reports several cases of injury to the spinal cord and gives 
the following cases as illustrating very well the symptoms 
of injury to the cervical cord : The first case is one of injury 
to the upper part of the cervical region ; second of injury 
about the mid-cervical region. Patient gave a history of 
having plunged head first into shallow water. Ten or twelve 
hours after accident no signs of injury to head, although it 
was somewhat retracted and movement of it caused intense 
pain. All four extremities paralyzed, the lower completely, 
the upper being capable of slight movement. Sensation 
lost from neck down. Breathing diaphragmatic. Patellar 
reflex present. Pupils contracted to pin points. Tempera- 
ture 104°. Mind perfectly clear. Priapism, and loss of 
control over bladder and rectum. Death occurred the day 
following injury. Autopsy revealed a fracture of the fifth 
cervical vertebra. The cord showed laceration at the point 
of fracture with extravation of blood extending about an 
inch vertically. Case 2. Patient fell about forty feet upon 
a rough, irregular surface. Examination showed lacerated 
wound of scalp, but no fracture of skull. Perfectly conscious; 
complete paralysis of lower extremities ; partial paralysis of 
upper. Sensation entirely lost from level of third rib down; 
impaired over chest and arms ; respiration diaphragmatic ; 
priapism marked ; paralysis of bladder and rectum ; pupils 



286 neurological. [March-June, 

finely contracted. Temperature 103° an hour after admission; 
reached 109° just before death which took place the day 
following reception of injury. Autopsy, laminae of fourth 
.and fifth cervical vertebrae fractured on both sides. Dura slit 
longitudinally ,there was extra-dural haemorrhage posteriorly. 
The cord opposite the fracture showed haemorrhage and dis- 
integration of its substance. The next case illustrates one 
of injury in mid-dorsal region. If complete, causes loss of 
motion and sensation below seat of injury. A lesion in the 
lumbar region involving lumbar enlargement causes loss of 
motion and sensation in all parts below, loss of control over 
bladder and rectum and loss of superficial and deep reflexes 
Case 3. Patient was crushed by a bank of earth falling 
upon him. No perceptible external injury. Entire loss of 
motion and sensation below level of first lumbar vertebra 
and loss of control over bladder and rectum. No 
loss of consciousness; superficial and deep reflexes 
abolished. Temperature on day of admission 102° ; 
remained at this point five days. Sank to normal ; did not 
rise again until just prior to death; bed sores of a trophic 
nature in gluteal region, and cystitis a later complication. 
Autopsy showed last dorsal and first lumbar vertebrae 
crushed and dislocated forward, compressing the cord and 
reducing it to an almost empty sheath. Case 4. Patient 
fell nine or ten feet striking upon his back and side. No 
loss of consciousness ; very little pain ; instant paralysis of 
the lower extremities ; slight scalp wound ; no fracture of 
skull ; marked projection of tenth dorsal vertebra ; total loss 
of power in lower extremities ; loss of sensation below 
umbilicus; bladder and rectum paralyzed. Cystitis and 
bed sores of a trophic nature developed. Patient died 
sixteen days after admission. Autopsy showed fracture of 
the tenth dorsal vertebra greatly compressing and crushing 
the cord. Several other cases are given showing the 
different forms of paralysis due to lesions of the spinal cord 
and the hollow cavities. The author is confident that the 
surgery of the future will make it possible to do something 
for these cases of injury to the spinal cord. {Med. News, 
March 18, 1893.) 

B. M. CAPLES. 

Myelitis Simulating H^ematomyelia. — Dr. Steell records 
a case of almost instantaneous onset of paralysis occurring 
in acute myelitis, which simulates spinal haemorrhage so 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 287 

closely as to make differential diagnosis almost impossible. 
Patient, girl of 13 years, shortly after feeling of weakness 
became paralyzed in limbs. On left leg and left side of 
abdomen and chest as high as seventh rib unable to 
distinguish between touch with head and point of a pin. 
This area ceases little to left of middle line of abdomen and 
chest. On right side is able to distinguish feeling of objects. 
Above seventh rib, sensation normal on chest and face. 
Tenderness on percussion over seventh cervical and first 
and second dorsal spines, pain in cervical and dorsal 
regions. In two weeks, after a restless period, patient died. 
Necropsy, spinal meninges normal ; cord soft in lower 
cervical region, firm at other parts; normal externally; no 
signs of hemorrhage or tumor growth. Microscopical 
examination revealed acute myelitis affecting grey matter 
chiefly ; normal structure of grey matter replaced by all 
infiltration and dilated vessels, white matter more affected 
around right anterior horn. The interesting characteristic 
feature is unilateral analgesia and thermo-ansesthesia, while 
tactile sensation is retained. (Lancet, Jan. 21, 1893.) 



Brown-Sequard Paralysis following Influenza, with 
Faradic and Franklinic Reaction of Degeneration. — A 
girl, aet. 17, formerly healthy, had influenza in November. 
A constant pain in the spine between the scapulae, as well 
as in the right arm and shoulder, remained after recovery. 
About two months afterward a weakness of the right leg was 
noticed. At the end of January a paralysis of the right leg, 
the bladder and rectum and anaesthesia of the entire left 
side of the trunk and left leg occurred during sleep. A 
weakness of the right arm was also noticed at this time. 
The rectal and vesical paralysis soon disappeared 
under electrical treatment and the mobility of the 
right leg became greater. About the middle of May, 
when Eulenberg first saw her, the right leg was dragged in 
walking with crutches, the left side and right arm were 
anaesthetic, the right pupil and palpebral fissure were 
smaller than on the left side and the right side of the face 
was appreciably warmer than the other. The paralyzed 
muscles were atrophic. A very minute electrical exploration 
was made and demonstrated the presence of ordinary 
(galvanic) R. D., total or partial, in almost all the affected 
muscles. In the extensor hallucis longus of the right leg, a 



288 neurological. [March-June, 

combined R. D. for the faradic and franklinic current, both 
direct and indirect, was found. The contraction was slow, 
with a still slower relaxation, the latter lasting up to four 
seconds. For the technical particulars the reader is referred 
to the original paper. All the qualities of cutaneous sensa- 
tion were reduced or abolished on the left side, while those 
varieties of sensation referred to as muscular sense seemed 
normal. The anaesthesia extended up to about the level of the 
axilla. The right leg was somewhat hyperaesthetic, the reflexes 
were increased. The right arm was analgesic and hyperees- 
thetic in the distribution of the ulnar nerve. In regard to 
etiology or nature of the lesion the author has no plausible 
theory to offer. The location of the lesion could be 
distinctly limited to a level of the seventh cervical segment 
by a consideration of a distribution of the paralysis. The 
franklinic reaction of degeneration is a rare phenomenon as 
only two cases have been reported by the author and 
Bernhard. In a footnote the author states that the paralysis 
of the right and anaesthesia of the left leg had improved 
considerably, the paralysis of the right arm had increased. 
(Prof. Eulenberg, Deutsch. Med. Wochenschr., No. 38, 1892.) 

O. J. KAUMHEIMER. 

The Topical Diagnosis of the Pupillary Symptoms of 
Tabes. — Dr. Guillery has an article on this subject in 
Deutsch. Med. Wochenschr. (No. 52, 1892.) The article is 
very full and cannot be abstracted in such a manner as to 
give its contents. This notice is given to call the attention 
of such of our readers as may be interested in the subject, 
to it. 

G. J. KAUMHEIMER. 

Posterior Root Sclerosis and Medullary Sclerosis of 
Ataxics. — Dr. Pierre Marie (Prog. Med., Dec. 24, 1892) has 
recently shown that the influence of sclerosis of the posterior 
roots in the production of medullary sclerosis of ataxics was 
first pointed out by Leyden and refutes the claim of Dejerine 
to priority. 

J. G. KIERNAN. 



Brain of Tabetics. — Dr. Nageotte (Mercredi Med., Feb. 1) 
has examined the brains of three ataxics dying without 
demonstrable mental symptoms. One of these (a 53-year- 
old man) presented the characteristic lesions of paretic 
dementia. 

J. G. KIERNAN. 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 289 

Syringomyelia and Allied Affection. — G. B. Pellizzi, 
(Rivesta Sperimentale, XVIII, III and IV, Dec 31, 1892) gives 
an extended critical review of the literature of syringomyelia. 
Morvan's Disease, lepra anaesthetica, Raynaud's Disease, 
scleroderma, xeroderma, etc., in which he states and passes, 
judgment on the various views that have been offered as to 
the pathogeny and relations of these disorders. We offer 
here a brief statement of the principal points only of his 
review. As regards the first of these, syringomyelia, he 
begins by noticing the still unsettled state of the question of 
its pathogenesis. The majority of authors hold that most 
cases are to be referred to the destructive absorption or regres- 
sion of gliomatous tissue. Hallopeau and Joffroy have 
reported cases that seemed to them due to myelitis of the 
grey matter. Langhans in 1881 published the opinion that 
circulatory stasis was the cause. Kronthal and Schultze 
have published cases in which this was apparently the cause, 
arising from cancerous tumors. Recently Rosenbach and 
Schtscherbak have experimentally produced cavities by 
compression and consequent sanguine stasis in dogs. 
Joffroy and Achard have also reported a case of non- 
gliomatous syringomyelia associated with Basedow's disease. 
The same authors in 1887 reported cases in which the 
cavities were referred to an arteritis obliterans. Recently 
Weigert and Achard, independently of each other, and 
proceeding by different methods, have suggested certain 
reservations to the glioma theory on the grounds of the 
neuroglia prolification in syringomyelia agreeing with the 
conditions ordinarily met with under the name of glioma 
and the peculiar development of the spinal cavities. 
Pellizzi in discussing the various possible causes of spinal 
cavities, while not endorsing fully the objections of Achard 
and Weigert, calls attention to the effects of meningitis as 
observed by Charcot, Vulpian, Simon and others. Another 
important lesion that probably sometimes induces the 
disorder in his opinion is spinal haemorrhage. This relation 
has recently, it is true, been denied by Charcot and Joffroy, 
on the grounds of the absence of pigment traces in the 
tissues, and the lack of history of sudden paralysis preced- 
ing the disease. Against the first of these objections 
Pellizzi claims that the color- variations in syringomyelia are 
analogous to those of apoplectic cysts and the structure of the 
walls of the two kinds of cavities is identical. To the 
second he replies that spinal haemorrhage may vary very 



290 neurological. [March-June, 

much in its extent, its course and in its symptons. Cases 
have been reported by Minor in which the paralytic 
symptoms of spinal traumatism disappeared within only a 
few days and were followed later by symptoms similar to 
those of syringomyelia. An old spinal haemorrhage that 
has been comparatively latent may revive the morbid 
processes that result in spinal cavities, and thus the clinical 
connection between the two be obscured. While Pellizzi 
admits the possible gliomatous origin of a majority of cases 
he yet thinks that there are many that may recognize 
altogether different causes. When we have a sufficient 
number of cases carefully reported both clinically and 
pathologically, which at present we have not, he believes 
that we will be able to determine with exactitude 
even intra vitam the pathogenesis of the vast syndrome that 
to-day passes under the name of syringomyelia, whether it 
be glioma, focal inflammatory lesions, meningitic alterations, 
spinal haemorrhage or arterial thrombosis, etc., etc. While 
the pathogenesis of syringomyelia is somewhat obscure, its 
clinical symptoms, so complex and varied, have been quite 
largely elucidated. They are reviewed at length and 
discussed by the author. (1.) Sensory disturbances, ansesthesia. 
An almost constant symptom is partial thermic anaesthesia, 
very often with integrity of the tactile and space senses, and 
extremely often accompanied with a partial analgesia 
occupying a zone more or less extended than the thermic 
disturbance. This thermic anaesthesia is not distributed 
according to the nerves, but is located on certain divisions 
of the trunk or limbs, sometimes clearly limited in the 
median line, but more often occupying one arm and part of 
the thorax or a more or less extensive segment of a limb. 
Besides its irregular distributions this thermic anaesthesia is 
not absolutely stationary but varies somewhat in situation 
and intensity. Thermic paraesthesia has also been observed. 
This thermic anaesthesia is usually first to appear but often 
it is accompanied from the beginning by the analgesia 
which, except in extent, corresponds with it very closely. 
Tactile, pressure and space anaesthesia are usually unim- 
paired, but this is not the absolute rule and has not the 
importance at first given it by Charcot. - A disassociation 
of the sensibility is met with in hysteria, and maybe absent 
in syringomyelia. In this disease also all forms of 
cutaneous sensibility may be diminished or lacking, 
and cases of this have been reported by Roth, 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 291 

Schlesinger, Starr, Rsmak, and others. The tactile, 
space, and pressure senses generally in these cases 
follow the same rules as to appearance and distribu- 
tion as the thermic and pain senses. The muscular sense 
is rarely affected, though Knoppek has reported an instance 
of its complete loss. The pupillary reflex to pain is lacking 
from the analgesic zone, and this is a good differential point 
between syringomyelia and hysteria, in which last it persists. 
Dejerine and Tuillant have reported restriction of the visual 
field in seven cases, affecting all colors, but especially the 
green ; it was least as to white. Subjective sensory symp- 
toms are always present ; the patients complain of abnormal 
sensations of heat, cold, constriction, formication, etc., 
and sometimes of violent pain even existing with the 
objective analgesia. (2.) Motor Disturbances. Paresis 
and paralysis may be merely the result of the progressive 
muscular atrophy, but they may also be the consequence of 
the syringo myelitic process invading the motor column and 
thus occur independently (Raymond.) Other motor symp- 
toms that have been noted are subsultus of special muscles or 
groups of muscles, spastic contraction of the legs, epileptoid 
tremor of the feet, and fibrillary or fascicular movements, 
all rather frequent phenomena. Motor inco-ordination is 
rare. Disorders of the sphincters are commonly lacking ; a 
unilateral myosis with diminution of light reaction is 
common. The tendon reflexes are affected irregularly, an 
increase is sometimes observed of the knee jerk, but there 
is generally a decrease in the atrophied limbs. The elec- 
trical reaction of the muscles varies according to their 
condition. It may be normal or abolished, degenerative 
reaction is not uncommon. (3.) Trophic Disorders. These are 
manifested especially on the skin and in the voluntary 
muscles. Muscular atrophy is one of the most prominent 
features of the disease. Usually the smaller muscles of the 
hand are first affected and the change gradually involves 
the forearm, shoulder and trunk. The legs are commonly 
uninvolved till an advanced stage of the disease. The 
cutaneous trophic disorders are variable, and may be very 
extensive ; sometimes they only involve the hand. The 
generalized trophic eruptions are commonly vesicular or 
pemphigoid, in some cases producing ulcers, sometimes the 
initial lesion is a sort of gangrene resembling bedsores. 
Oheloid is sometimes a sequence. Blocq has described a 
case in which a vitiligo covered a large part of the bodily 



292 neurological. [March-June, 

surface. When the ulcers are located in the hand, they 
have been seen to present all the characters of mat perforant, 
Chipault has reported a case of an identical lesion of the 
foot. Brunzlow has also described similar cases. Thicken- 
ing and glossy skin have been observed in the hand (Roth) 
and gangrene of the extremities has occurred. Whitlows- 
are not uncommon and their production is favored by the 
facility afforded by the analgesia to traumatisms. The 
nails are also often affected ; the}' become thickened and 
brittle, etc. and at times are shed spontaneously. The 
alterations of the bones and articulations are verv common. 
luxations and fragility of the bones and especially arthro- 
pathies are very frequently met with ; the last named are 
particularly frequent in the joints of the upper extremity. 
The spinal deviation, seen in more than half of the cases, is 
also probably to be attributed to a trophic involvement of 
the vertebrae. (4.) Vaso-motor disorders. These are nu- 
merous and varied. The most common is urticaria provocata; 
many patients present the phenomena of auto- or dermo- 
graphy. Other lesions are local oedema and cyanosis, 
lowered temperature of the extremities or other parts, 
tumefactions, etc. (5.) Seer 'etory disorders. The perspiration 
is readily affected in syringomyelia ; it is rarely diminished, 
is generally increased ; the hyperidrosis is usually in the 
affected zones, only slightly more irregular in its distribution. 
It is variably in duration, sometimes appearing throughout 
the disease,at other times only for a few days or hours at a 
time. Some authors have observed also anuria, polyuria, and 
alterations of the salivarv and lachrymal secretions. It will 
be readily seen that the symptoms of syringomyelia are due 
to lesions of diverse spinal centers. Pellizzi suggests that 
careful clinical studies of the disorder may, in connection 
with equally thorough pathological studies of the cases, 
afford valuable data and assist in determining the ph^siol- 
ogy of the cord. The first of the other conditions or 
supposed other morbid states that is taken up and compared 
is Morvan's Disease. Morvan's Disease. This, as described 
by Morvan, who published his first seven cases 
in 1883, is characterized by three cardinal symptoms-, 
viz.: analgesia, paresis and whitlows. The analgesia may 
be slight in the beginning, but after the whitlows have been 
numerous and the skin is thickened and cracked, it becomes 
complete and may involve the whole of one arm or both 
arms and in rare cases, the lower extremities, the face, and 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 293 

the trunk. In these cases it is not total, there is always 
more or less of the surface uninvolved. The distribution 
is closely analogous to that in syringomyelia and not accord- 
ing to the territories of separate nerves. W hile Morvan in sisted 
on this fact of analgesia especially, but it is not seldom 
accompanied by tactile and thermic anaesthesia also. 
Recently LaVecchia has argued that dissociation of the 
sensibility is not of great value in differentiating Morvan's 
disease and syringomyelia, and the literature of the subject 
favors the same conclusion. In his first publication Morvan 
claimed that paresis was constant, but later studies have 
shown that this is incorrect. It was lacking in the observa- 
tion of Guelliot and Broca, and also in these cases reported 
by Morvan himself in 1886. According to Morvan the 
reaction of the muscles to the faradic current is lessened ; 
others (Hanot, Oger de Speville, Guinon and Dutil, etc.) 
find it unaltered. The tendon reflexes vary as in syringo- 
myelia. Whitlows are the characteristic of Morvan's disease. 
Sometimes they are preceded by pain, sometimes by 
analgesia, sometimes there are no prodromata. They have 
all the characters of the affection as it is occasionally 
met with in syringomyelia. The mutilations due to them 
are not confined to the hands, they may occur on the feet, 
and have the characters of mat perforant (Verchere). 
Marchiafava and Bignani have recently published two cases 
of Morvan's disease in which it began in the right loot, 
passed then to the left, and later involved the hands. Other 
important trophic disorders are arthropathies, fractures from 
slight cause, trophoneurotic ulceration, etc. Scoliosis is 
frequently coincident with Morvan's disease, about one-half 
the cases according to the authorities. Vaso-motor disorders 
occur, especially in the hands, the parts are violaceous and 
cold. In a case of Souque there was a reddish erysipelatous 
appearing oedema on the dorsal face of the metacarpus and 
carpus, and lower third of forearm. In the special senses 
we find that Morvan found narrowing of the visual field in 
five cases out of eight, in three only on one side ; in two 
cases of Guinon and Dutil in one there was amaurosis on 
the left, and in the other restricted visual field on the right ; 
there was narrowed visual field in the second of the cases 
reported by Joffroy and Achard. It is stated that weaken- 
ing of audition and abolition of taste and smell have been 
observed. Only three necropsis of Morvan's disease are 
reported, and the lesions found consisted in alterations of 



294 neurological. [March-June, 

peripheral nerves and spinal lesions largely corresponding 
to those of syringomyelia. In an autopsy of a patient of 
Prouffs made by Gombault and Rebaul, there were found, 
besides neuritic lesions of the nerves of the members, 
excessive development of interstitial tissue and vascular 
lesions in the posterior columns and cornua, also involving 
the gray substance. Owing to a pronounced scoliosis the 
cord could not be extracted in a condition to satisfactorily 
ascertain or exclude the existence of cavities. Joffroy and 
Achard, in the autopsy of a typical case of Morvan's disease, 
found a typical gliomatous syringomyelitic cavity, and in 
another later one, they found a cavity with walls of 
neuroglia, and with the characters of typical syringomyelia. 
In both these cases there were also alterations of the periph- 
eral nerves, but not more prominent than are often met 
with in chronic disorders of the nerve centers. In the discus- 
sion of the symptoms, Pellizzi points out that Roth, in 1887,had 
claimed the identity of Morvan's disease with syringomyelia, 
and that none of the symptoms are abolutely special to 
either. The whitlows, Morvan's essential symptom, were 
observed in syringomyelia by Roth in half his cases, in four 
cases of Bruhl, and in others reported by Schultze, Czerny, 
Joffroy and Achard, and Charcot. It does not therefore 
seem so infrequent and when observed the characters are 
identical with those in Morvan's disease. The sensory 
dissociation is not pathognomonic of syringomyelia, as we 
have seen it occurs also in hysteria, and it has been reported 
in Morvan's disease by Church, Grasset, Sacho and LaVecchia. 
The other symptoms, atrophy, paresis, spinal deviation, 
trophic disorders, disturbances of vision, are also more or 
less common to both affections. While the pathological 
results of Gombault and Rebaul appear to indicate a 
peripheral origin of Morvan's disease, there is some question 
as to the exact pathological value to be attributed to nerve 
lesions of the kind which has been questioned by Brissaud. 
Thus while it is beyond question, Pellizzi holds, that periph- 
eral nerve lesions exist in Morvan's disease and probably 
aggravate the trophic and sensory disturbances, the depend- 
ence of the whole symptomatology of the disorder cannot, 
with certainty and with our present knowledge, be attributed 
to them. The observations of Joffroy and Achard, on the 
other hand, bear strongly against the theory of the distinction 
of the two disorders. The conclusions of Pellizzi, from his 
critical study of all the literature, are, that, while there is a 



V 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 295 

great analogy between the two forms, it is impossible to 
decide positively as to the unity or duality of the disorder. 
In any case Morvan's disease has special marked characters 
that distinguish it either as a species or a variety ; such as 
the localized character of the lesion for long periods, its slow 
progress, as compared with syringomyelia, the less severity 
of the trophic lesions, the less percentage of bilaterality, etc. 
There is no symptom decisive as to the central or the 
peripheral origin of the disease. After some remarks on 
the effects of peripheral neuritis, in which he shows that it 
has generally clinical difference from syringomyelia and 
Morvan's disease, Pellizzi passes to the discussion of the next 
allied disorder. Lepra anaesthetica. — Not very long since, 
Zambaco, who has had large experience with leprosy in the 
Orient, gave it as his opinion that lepra anaesthetica, 
syringomyelia and Morvan's disease were identical. Clinical- 
ly there are strong resemblances, but pathologically the case 
is different, the Hansen-Niesser bacillus and the lack of the 
organic lesions in the cord distinctly separate lepra from the 
other disorders. The difficulties of diagnosis are, however, 
sometimes very great, as is instanced by a patient who had 
contracted lepra in Tonquin, and who was first diagnosed by 
Rendu as a case of neuritis, later as syringomyelia compli- 
cated with the former affection. Later Thibierge and 
Charcot diagnosed it as lepra, and the former referred to it 
as showing the resemblance of the three disorders though 
not admitting their possible identity. Very recently 
Zambaco published the following conclusions of a thorough 
study of lepra: (1.) Autochthonous lepra under its 
anaesthetic form exists at present in Brittany: it preserves 
its classic characters, but is mild in most cases, incomplete 
-and attenuated ; usually shows itself by only one or two 
symptoms. Similar cases occur in countries where lepra x is 
prevalent and there lack the pigmented patches, nodules, 
and tubercles, on which is based the distinction between syrin- 
gomyelia, Morvan's disease, and lepra. (2.) In almost 
every region in Europe there are at present typical 
cases of this attenuated lepra. (3.) Morvan's disease, 
frequent in Brittany, where lepra also is found, is only a 
relic of the latter. (4.) The cagots of the Pyrenees, the 
Jcakons of Brittany, the agots of Spanish Navarre, the gabets of 
Gaienne, the caeths of Southwestern Britain are only 
descendants of lepers. (5.) At Constantinople, indigenous 
leprosy is only met with in the descendants of Spanish Jews 



296 neurological. [March-June, 

who have been acclimated there three centuries. Morvan's 
disease is therefore only Danielson's lepra ansesthetica 
attenuated, the same is true of some cases at present referred 
to syringomyelia. In a very recent work Roussel has 
accepted the same conclusion. Lejaid has studied the cagots 
of the Pyrenees and noted trophic lesions like those of 
Morvan's disease. They are considered and treated as they 
were in times of leprosy. Magitat has found similar cases 
in the Beam territory, where they pass under the same 
name, cagots. From historical documents, local traditions, 
etc., he concludes that there is here a survival in a mild 
form of leprosy as it existed in southwest France in the 
time from the thirteenth to the sixteenth centuries. Vidal 
has objected to these conclusions that the lepra bacillus has 
not yet been found in these cases. It is only certain that, 
if it is found, it will be irrefutable evidence in favor of 
Zambaco's theory. Pailizzi, from all these facts, is inclined 
to believe with Zambaco, that further investigations will 
very probably refer to peripheral infection (lepra?) perhaps 
all cases of Morvan's disease, many of syringomyelia, and 
possibly also some of those defined as Raynaud's disease. 
Raynaud's Disease. While this seems more certainly a 
morbid species than does Morvan's disease, yet its symptoms 
are largely included in the manifold syndrome of 
syringomyelia. Roth and also Thibierge have noted the 
similarity, and Schlesinger has argued that part of the cases 
of Morvan's disease are really syringomyelia, and others are 
Raynaud's disease. The symptoms of this disorder, consist- 
ing in local anaemia and asphyxia with cyanosis followed 
by gangrene are reviewed in full and the variations observed 
by various authors noted. The theories of its pathology are 
also discussed, and Pellizzi concludes that it may be some- 
times of central, sometimes of peripheral origin. There are 
some clinical facts not explainable by the peripheral theory, 
such as its connection with the general conditions of anaemia, 
chlorosis and neuropathic states, the sudden symmetrical 
attacks, etc., which support Raynaud's theory of the central 
origin of the malady, while the nerve lesions that have been 
met with by Petres, Wylesworth, Thompson and others 
speak on the other hand for its peripheral origin. Other 
affections, scleroderma, xeroderma, mal perforant are 
noticed more briefly, and in the main the author of the 
review suspends judgment as to their pathogeny and exact 
relations. He concludes by saying: However much it is 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 297 

sought to obtain all available facts, and only on the basis of 
these can any discussion be conducted, it must be agreed 
that our actual knowledge of the majority of the forms 
described, especially on their pathogenetic side, is far from 
being complete or certain. What part infection, intoxica- 
tions, spinal lesions, those of the peripheral nerves, or of the 
vessels, may have, will have to be decided by future studies 
when other observations, not so much numerous as accurate 
and complete, shall be added to the few parts we now 
possess. 

H. M. BANNISTER. 

Case op Syringomyelia, with Autopsy. — Dr. James 
Hendrie Lloyd publishes a case with illustrations of sections 
of the spinal cord at different elevations. The cervical 
enlargement was broadened and flattened. A large cavity 
was found begining in the lower part of the medulla, 
broadening out in the cervical region and extending into 
the dorsal cord. It did not extend into the lumbar enlarge- 
ment. The cavity was situated a little to the right side of 
the cord. Most of the multipolar cells in the anterior horns 
of the cervical enlargement were atrophied and granular. 
The lateral pyramidal tracts degenerated and the direct 
cerebellar tracts partly so. At some levels the latter were 
only slightly degenerated ; more degenerated on the right 
than left and pretty generally degenerated in the medulla. 
Owing to distortion the condition of Clark's column could 
not be definitely determined. The report says : "This cord, 
followed through its whole length, presents an epitome of 
the gliomatous process in all its various stages. Thus, in 
the medulla the process is diffused in various areas, and a 
cavity has not yet been formed. In the cervical region the 
cavity is formed, and is very extensive, with secondary 
effects in the white matter; in the dorsal region the process 
is more limited, and the glioma tends to one side ; while in 
the lumbar enlargement the process is still in an early 
stage, prior to the formation of a cavity. " The remainder 
of the description of microscopic appearances is interesting 
but rather too full for quotation. We recommend those 
who are interested in this matter to obtain a copy of the 
reprint from the author. ( University Medical Magazine.) 



Syringomyelia and Leprosy. — Dr. Zambaco (Revue 
MMico-Pharm. Dec. 15, 1892) claims that syringomyelia is 



298 neurological. [March-June, 

a manifestation of leprosy, basing this opinion on researches 
among the cagots of the Pyrenees. There is an error evident 
of claiming that because leprosy does produce lesions 
identical with those found in syringomyelia, this neurosis 
must in all cases be due to leprosy. Jt G kiernan. 



Differential Diagnosis Between Leprosy and Syringo- 
myelitis. — Prof. N. Kalindero has frequently found cases of 
leprosy, at the outset, simulating syringomyelitis. He gives 
the following example : A man otherwise healthy, with no 
leprous history, presents anaesthetic and analgesic spots and 
disturbances of sensation, the temperature sense and of the 
electrical reactions. He sums up the differential diagnosis 
as follows: In favor of syringomyelia; 1. The dissocia- 
tion of the sensory disturbances ; 2. The integrity of the 
superficial facial mucles ; 3. The absence of spots in the 
face ; 4. The integrity of the hair ; 5. Deviation of the 
spinal column. The following symptoms speak in favor of 
leprosy; 1. Disappearance of tactile sensibility; 2. 
Atrophy and paresis of the superficial facial muscles; 3. 
Nodosities in the course of the nerves ; 4. The presence 
of spots in the skin, especially if they are anaesthetic; 5. 
spontaneous shedding of phalanges ; 6 Changes in the 
nails ; 7. Partial or complete loss of hair. In obscure 
cases, the application of a blister has been of great assistance. 
In the contents of the bleb about the third or fourth day 
the bacillus of leprosy can be found in leprous patients. 
(Wien. Med. Presse, No. 39, 1892.) G> Jm kaumheimer. 



Secondary Spinal Degenerations. — Dr. Sattas recently 
reported {La Irib. Med. Mch. 9, 1893) a case in which five 
sacral nerve roots were compressed by a sacral cancerous 
tumor. At the spinal origin of the nerves affected there 
were found on autopsy secondary degeneracy of the column 
of Clark as far as the tenth dorsal. The columns of Goll 
were also affected. j. G . KIERNAN , 

Bacteriological Examination in Cases of Severe 
Involvement of the Nervous System following Influenza. 
— Dr. A. Pfuhl has found in five cases in which the 
symptoms on the part of the nervous system were pro- 
nounced and rapidly fatal, the Pfeiffer-Canon bacillus in the 
meninges, cerebral substance and ventricular fluid. {Berlin. 
Klin. Wochenschr.j Nos. 39-40, 1892.) G . j. kaumheimer. 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 299 

Hysteria Simulating Hemiplegia. — Comby reports the 
case of a woman 42 years of age who, a fortnight before 
admission into the hospital was seized with transient loss of 
power in left extremities. Just before admission a similar 
attack affected right side; pharyngeal reflex abolished. 
After a few days treatment by electricity patient able to 
walk and use her arm; was preparing to leave hospital 
when she was seized by three violent hysterical convulsions 
at short intervals. The third ended in her death. At 
post mortem brain, membranes, heart, lungs and kidneys 
appeared healthy. Raymond suggested that the cause of 
death was not hysteria. Urine had not^been examined and 
it was probable that the paroxysmal retention of urinary 
poison had set up the fits. Siredey had observed a fatal 
attack of Jacksonian epilepsy where no organic lesions were 
found after death. (British Medical Journal, Dec. 31, 1892. \ 

Urinary Toxicity and Hysteria. — Gilles de la Tourette 
(Prog. Med., Dec. 10, 1892) states that the results obtained 
from the injection of urine of hysterics, carefully guarded to 
avoid individual peculiarities, are contradictory and value- 
less. His results differ from those obtained by Bosc. 

J. G. KIERNAN. 



Hysterical Simulations of Organic Brain Disease. — 
Dr. Ghilarducci cites (Arch, de Neur., Nov., 1892) several 
cases in which hysteria simulated organic brain disease 
varying from epilepsy to cerebral syphilis. 



J. G. KIERNAN. 



Case of Hysterical Astasia- Abasia. — Dr. L. Bremer 
reports a case in which the patient sued the owner of a 
passenger elevator for injuries; the case being one of 
hysterical astasia-abasia in the author's opinion. The jury 
found for the defendant. He states that recently in Spain 
six persons were sentenced to prison on the false charges of an 
insane hysteric. The Medico-Psychological Society, of Paris, 
succeeded in demonstrating that the accuser was insane and 
the prisoners were set at liberty. (Jour, of Nervous and 
Mental Diseases, Jan., 1893.) 



Hysteria with Spinal Irritation in a Man. — Dr. L. P. 
Wallbridge reports the case of a man 48 years of age who 
received a fall ; on getting up felt severe pain in head and 



300 neurological. [March-June, 

back of neck. When working where work requires stooping 
head and back of neck pained him so that he 
was compelled to cease. About ten years ago had 
severe pain in back of neck, chilly sensation pas- 
sing from back of head down whole course of 
spine, became rigid, was carried to bed, had several convul- 
sions. Any unusual excitement would precipitate one of 
these attacks; he will become rigid, then clonic; loses con- 
sciousness and when he regains consciousness sheds tears. 
From the occipital protuberance down for about three inches 
from the cervical spine is the sensitive area, pressure in this 
region causes patient to have a convulsion. (iV. Y. Medical 
Journal, Dec. 3, 1892.) _ 

Hysterical Rapid Respiration. — Dr. Wier Mitchell has 
a paper in the American Journal of Medical Sciences dealing 
with this obscure and interesting affection. From experi- 
ence is able to formulate a description of symptoms 
associated with the condition. The breathing, he says, is 
largely upper costal, sometimes exclusively so, and the 
preservation of the relative share between that and the 
diaphragm is rare. As a rule it is superficial and without 
appearance of effort. In the early stage patient is ignorant 
of the existence of the symptoms. When the knowledge is 
acquired respiration rate increased by excitement such as 
the approach of the nurse or medical attendant. As a rule 
the symptom occurs only just after sleep ; may be absent, 
usually is so during sleep. Sometimes the symptom is the 
only distinct expression of hysteria, or is not present until 
patient is emotionally excited. Author does not think that 
the type of breathing is a possible voluntary product. 
Regards the affection in males as distinctly rare. He 
related several cases which bear out this description : One 
in which there was a peculiar and anomalous eruption on 
the leg somewhat rupial in character, which appeared at 
first as a mass of pimples. During a stage of trance these 
became confluent and formed a scab, an excellent illustration 
of which is given in the paper. Scab was removed and under 
it was found a grayish-white fibrinous material from the 
surface of which oozed a little blood. Skin was thickened 
round edges, hardened and hyperaemic, and the area was 
very sensitive. Nothing else unusual discovered in patient's 
condition except marked contraction of color-fields. He also 
refers to different forms of rapid respiration, and graphic 



1893.] PATHOLOGY AND SYMTOMATOLOGY. 301 

records of the varieties of these were given. The paper 
will assist materially in elucidation of an obscure and 
unusual condition. 

B. M. CAPLES. 

Hysterical Sleep and Hypnotic Suggestion. — Prof. E. 
Hitzig publishes a series of interesting observations on a 
case of hysterical sleep. A laborer, aged 20, sustained an 
injury of the head and left forearm, which kept him in the 
hospital for about 12 weeks. Before his wounds had 
completely healed, he showed peculiar intervals of sleep. 
At first these appeared every two to three weeks, but the 
interval gradually decreased to one week. These spells 
were preceded by excitement with headache and increase of 
temperature, which occasionally rose to 39.9° C. This was 
followed by sleep usually lasting from evening to noon of 
the third day thereafter. There was complete amnesia for 
the period of sleep. Food was never taken during this time, 
but he woke up during some of. the sleeping spells to 
urinate and drink. He said that this was caused by the 
nurse pressing the scar upon his arm. After the sleep 
passed off, he complained of headache for several hours, but 
soon began to take nourishment freely, Examination 
showed a very sensitive scar on the left arm. The scars on 
the head were not sensitive. The patellar reflexes were 
much exaggerated. The patient was found to be very 
easily hypnotizable. Believing that these nsitive scar on the 
arm acted as a hypnogenic point Hitzig anaesthetized it, but 
had to suggest anaesthesia of the entire forearm to accom- 
plish this. The patient had seven sleeping spells while 
under observation, at intervals of about seven days. Once the 
interval was 13 days, but after the usual prodromes, profuse 
•epistaxis occurred on the seventh day, evidently an equival- 
ent of the sleep. Various attempts at shortening or 
aborting these sleeping spells failed, until H. induced 
hypnotic sleep several hours before the hysterical sleep was 
to set in, and then suggested that he would awake at a certain 
signal on the following day. This he did and for over 
three months no further attacks of sleep occurred. The 
prodromes, however, occurred at variable intervals and the 
hyperesthesia of the scar upon the arm remained. Hitzig 
■adds some observations upon the bodily functions during 
these paroxysms of sleep. During the prodromal and 
■somnolent stage a constant loss of weight ranging from four 



302 neurological. [March-June,, 

kilos in the first to 0.5 kilo in the last attack. The average 
was near 3.25 kilos, and when daily weighings were made it 
was found that the lessened loss of weight in the prodromal 
stage was balanced by an increased loss on the somnolent 
stage. Corresponding to this, the excretion of nitrogen was 
increased, although he is not able to present complete 
figures. Hitzig gives those of the fourth attack as follows : 
on the day before the beginning of the prodromes 24.6 gm. 
urea ; first day 30.21 gm. ; second day 44 gm. During the 
sleep it was diminished, while after, it was again increased, 
being 37.95, 33.25, and 30.4 gm. respectively on three 
occasions. The volume of urine excreted during the sleep 
varied from 800 to 1000 C. C. Hitzig does not attempt to 
draw any deductions from this case but simply presents it 
on account of its many interesting features. (Berlin. Klin. 
Wochensch., No. 38, 1892.) 

G. J. KAUMHEIMER. 



The Tongue in Peripheral Facial Palsy. — Hitzig 
points out that authors vary much in regard to the protru- 
sion of the tongue in facial paralysis. Some state that it is 
put out straight, others that it deviates to the sound side,, 
and still others that the deviation is to the paralyzed side. 
Hitzig states that in the lighter forms, the tongue is always 
put out straight, but that in severe and protracted cases it 
deviates to the sound side if at all. But if it does, and the 
angle of the mouth on the paralyzed side be drawn to its 
proper place the tongue will straighten. He explains this 
as follows: The tongue is accustomed to keep at an equal 
distance from each oral angle. When it finds that it is 
nearer one angle it deviates to the other side until its 
median position between the two angles is restored. {Berlin 
Klin. Wochenschr., No. 50, 1892.) 

G. J. KAUMHEIMER. 

Lead and Arsenical Paralysis. — Jolly showed a patient 
who presented a typical case of arsenical paralysis after a 
single suicidal dose, before the Medical Society of Berlin. 
He pointed out that in arsenical paralysis the lower 
extremities are usually affected first and most severely and 
that the succession of the symptoms showed the paralysis to 
be due to a peripheral neuritis, a point stated by Leyden as 
long ago as 1875. Although autopsies are rare in these 
cases, certain changes have been found (syringomyelitis, 
changes in the ganglion cells) but as these are neither 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 303 

uniform nor sufficient to explain the symptoms, Jolly 
believes them to be accidental. On the other hand, lead 
palsy, by its selection of certain groups of muscles in typical 
order, has been considered by a number of authors, foremost 
among whom is Erb, to be of central origin. A small 
number of autopsies in which poliomyelitic changes were 
found in the cervical cord, and experiments by Stieglitz, who 
produced poliomyelitis and palsy in animals by the inhal- 
ation of lead, support this view. Jolly communicates the 
details of an autopsy. The patient had had almost com- 
plete paralysis of all the extremities, beginning about 16 
months before death. Serial sections of the hardened cord 
showed that the ganglion cells of the cervical cord were 
rather few in number, and in certain of the sections some of 
the cells were somewhat rounded and, rarely, a broken up 
cell was seen. The usual changes were found in the 
muscles and nerves. Jolly does not attribute any causative 
influence to the changes in the cord but believes that lead 
paralysis like arsenical paralysis, is of peripheral origin. 
The marked tendency toward improvement under treat- 
ment would also be difficult to understand if we assume a 
central origin. (Deutsch. Med. Wochenschr., No. 5, 1893.) 

O. J. KAUMHEIMER. 



Peroneal Paralysis. — A number of cases of peroneal 
paralysis were shown at the meeting of the Charite Physi- 
cians, at Berlin, Feb. 18, 1892, and elicited a good deal of 
discussion. Hiinermann showed three patients in whom 
the paralysis was the result of parturition. Case I. A severe 
forceps case complained of pain in the left leg as soon as the 
child was born, complete peroneal paralysis developed, which 
had existed over nine months with complete R. D. Case II. 
Complained of pain in the right leg during labor, the further 
history being like that of the previous case. Case III. 
Was very similar to case II. Hiinermann attributes the 
isolated peroneal paralysis to pressure of the child's head or of 
instruments upon the fourth and fifth lumbar roots, which 
go to form the peroneal nerve. Disproportion between the 
foetal head and maternal pelvis favors the occurrence of this 
accident, even before instrumental interference. Another 
cause of these paralyses is pressure of inflammatory exuda- 
tions. Klamroth presented a man who had been receiving 
intramuscular injections of mercury into the gluteal muscles 
for syphilis. At the fifth injection intense pain in the entire 



304 neurological. [March-June, 

left limb resulted, the knee being drawn up to the chin. 
The pain was constant and agonizing and within 48 hours 
a complete paralysis of the muscles supplied by the peroneal 
nerve had resulted. This had persisted with complete R. D. 
Klamroth attributes this accident to a high division of the 
sciatic and puncture of the peroneal branch by the needle. 
Jolly pointed out that hysterical paralyses were also likely 
to occur during pregnancy and labor, and called attention 
to paralysis due to osteomalacia, which he had observed in 
Strasburg and had been described by Koppen. Bernhard 
stated that neuritis was not to be forgotten as a cause of 
paralysis in the puerperium and that Martius, Kast and 
Mobius had described a neuritis puerperalis. (Berlin Klin. 
V/ochensch., No. 38, 1892.) 

G. J. KAUHHEIMER. 

Paralysis after Pneumonia is very rare, according to 
Dr. Boulloche. He divides such cases into two groups 
according as they occur in the primary or later stages of the 
disease. Most of the former group are of a hemiplegic 
type. Both youth and age are affected. Sometimes the 
paralysis completely masks the lung trouble, which is only 
discovered at the post mortem. The only pathological con- 
dition found in the brain in such cases was an atheromatous 
condition of vessels in Sylvian fissure. Hemiplegia is often 
accompanied by aphasia but recovery is generally rapid. 
In some of the fatal cases there is meningitis extending 
over the cerebrum, with atheroma. The second form of 
paralysis does not appear until last stages of convalescence 
from the pneumonia. Symptoms resemble diphtheritic 
paralysis. Sensation slightly affected, and paresis attacks 
lower extremities more than upper. Sphincters remain 
free. The probable cause of paralysis is toxic. Prognosis 
generally favorable. In a few cases a general weakness of 
nervous system remained. (The Lancet, Dec. 10.) 



Aphasia and Paralysis After Uremic Coma. — Dr. 
Brunet (Jour, de Med. de Bordeaux, Mch. 12, 1893) reports the 
case of a 43 year old non-luetic man who after an attack of 
ursemic coma developed aphasia, left facial paralysis, and 
right arm paralysis. On the exterior cerebral surface there 
was no special lesion other than slightly increased vasculari- 
zation of the hemispheres. There was a slight depression 
of the left ascending frontal and parietal convolutions. 



1893.] PATHOLOGY AND SYMTOMATOLOGY. 305 

There was no hemorrhagic extravasation. The arteries of 
the base were not atheromatous but those of the external 
face were so in patches. In Brunet's opinion the neurotic 
symptoms were due not to organic changes, but to an auto- 
intoxication by toxines retained in the blood of ursemics. 

J, G. KIERNAN. 



Pseudo-Hypertrophic Paralysis. — Dr. Pasteur exhibited 
a case of pseudo-hypertrophic paralysis in a youth, aged 17, 
before the Medical Society of London. The thighs were 
extremely small whilst the calves were typically enlarged. 
The wasted parts had diminished in electrical excitability. 
The case was remarkable in that it appeared to have become 
quite arrested in an early stage. The lad's intellect was 
good, father was an epileptic. {Lancet, Feb. 4, 1893.) 



B. M. CAPLES. 



Metabolism in Paralysis Agitans. — Schaefer, in a care- 
ful examination of the excreta in a case of paralysis agitans, 
reaches the following conclusions: 1. The absolute 
quantity of nitrogen in the excreta was greater than that 
present in the food taken by the patient. 2. The average 
amount of tissue change for each kilogram of body weight 
was greater than the average observed in healthy men, 
leading a quiet life, and was also greater than in young 
men engaged in occupations which require great bodily 
exertion. 3. The increased metabolism was probably due 
to the great amount of work thrown upon the muscles by 
the involuntary movements of the disease. 4. The amount 
of phosphoric acid in the urine showed no change from the 
normal. 5. The chlorides in the urine were slightly 
increased. (Archiv fur Psychiatiie, Vol. 14, No. 3.) 

JOS. KAHN. 

Pathology of Paralysis Agitans. — Dr. von Ketscher 
writes on this subject. He says the cases of paralysis 
agitans, with reference to their pathological anatomy, are 
divisible into two classes — those in which the examination 
has furnished negative results, and those in which various 
changes have been found in the nervous system, such as 
hyperplasia of the connective tissue and neuroglia of the 
spinal cord, alterations in the nerve tissue itself and vascular 
changes. Similar changes are described as occurring in the 
medulla and pons. Three cases of undoubted paralysis 



306 neurological. [March-June, 

agitans have been investigated by the author. The nervous 
system, central and peripheral, was examined, and in all 
three cases changes were found in both regions. The 
nervous structures showed atrophy, the ganglion cells of the 
brain were deeply pigmented and altered in form, the nerve 
fibres both in the peripheral nerves and in the spinal cord 
were degenerated, and had in some instances disappeared. 
The muscular fibres also were atrophied or degenerated. 
The neuroglia was thickened, especially around the vessels, 
and mostly in the posterior and lateral columns. The 
vessels also were altered, their walls thickened and there 
were miliary aneurisms and small haemorrhages present. 
Similar changes, but slighter in degree, were found as senile 
changes in patients not the subjects of paralysis agitans. 
The author concludes with Borgherini and others that 
paralysis agitans is only the expression of an extreme and 
premature senility of the nervous system, and he is of the 
opinion that the primary changes are in the vessels, those 
of the nervous structure being secondary. (Lancet, March 
25, 1893.) 

B. M. CAPLES. 

Paramyoclonus Multiplex. — Lemoyne reports the follow- 
ing case: Man aged 41, in good health, received a mental 
shock, very narrowl} 7 escaping being crushed by falling 
timber. For several days after accident mind was engrossed 
by recent peril ; no sleep during first 72 hours ; palpitation 
and pain in cardiac region. Slight tremor in all limbs 
appeared in a few days, soon developed into attacks of clonic 
spasms recurring with great frequency, increased by atten- 
tion or emotion, could be induced by pricking or compressing 
the muscles. Amplitude and force of contractions gradually 
rose to an acme in which hands and fingers were contorted, 
fore arms convulsively extended, arms thrust forward or 
behind head, shoulders raised, knees adducted, neck arched 
backward. These clonic movements either ceased abruptly 
or by degrees, less frequent at night but often interrupting 
sleep; diaphragm affected, causing hiccough or panting 
respiration. Echolalia and "echokinesia" present in slight 
degree ; latter happened especially when imitated movement 
was sudden and unexpected. When lying in bed lower 
limbs free from spasm, when standing or walking, if an 
attack supervened, titubation, extension of toes, and elevation 
of heels observed. Patient became a paranoiac with suicidal 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 307 

propensity. The author believes this case is the first in 
which paramyoclonus has been associated with mental 
derangement and the only one in which echolalia and 
echokinesia have coexisted. The instantaneousness of the 
spasms, their absolute inco-ordination and the influence 
upon them of the patient's posture differentiate the affection 
from convulsive tic. He regards paramyoclonus, convulsive 
tic, and electrical chorea as varieties of the same neuro- 
pathic state. (British Medical Journal, Dec. 31, 1892.) 

B, M. CAPLES. 

Progressive Muscular Atrophy. — In the British Medical 
Journal for January 28th is the following from Dr. Homen, 
describing a case presenting a combined form of progressive 
muscular atrophy originating from peripheral nerve injury. 
Patient's age, 27 ; in good health when accident occurred, 
fell asleep with right hand underneath ear and arm beneath 
body. On awaking found that he had wrist-drop and motor 
paralysis of the hand. At the end of the week regained 
slight power in the extensors. Some months later pro- 
gressive atrophy commenced in the- muscles of the hand, 
especially the thenar, then slowly extended to the forearm, 
shoulders, left forearm and hand and fibrillary contractions 
were observed in affected muscles. The pectorales majores 
showed only quantitative electrical changes and were not 
greatly wasted. No " tendon reflex " in upper limbs ; major 
present. No sensory disorder at any time ; small pieces 
excised from several of the wasted muscles exhibited great 
degeneration and atrophy in many of the fibers, the 
pectoralis being least affected. Slight hypertrophy induced 
in a few of the fibers. Homen's opinion is that the injury 
of the musculo-spiral nerve induced anterior polio-myelitis. 
Superadded to this was humero-scapular progressive 
muscular dystrophy. Etiological relationship between the 
dystrophy and central affection could not be determined. 

B. HI. CAPLES. 

Arthropathia Muscular Atrophy. — Kahane, in a paper 
read before the Vienna Medical Club, gives a resume of our 
knowledge of this subject. The clinical pictures agree to a 
great extent. In the majority of uncomplicated cases the 
atrophy is moderate, the reflexes and sensation are normal 
and there is no R. D. Loss of function is not always pro- 
portionate to the atrophy and vice versa. The prognosis is 



308 neurological. [March-June, 

usually good. Therapeutically, massage and electricity are 
of the greatest value. Three theories have been offered to 
explain this phenomenon. 1. Inactivity. Against this 
has been urged, 1, that the atrophy may show itself even if 
the inactivity has lasted but a few days, and, 2, that 
frequently in cases of central origin there is no atrophy even 
after paralysis of several months duration. 2. Anatomical 
lesions. Strumpell has assumed a myositis as the cause of 
the atrophy. This has not been proven as yet, although not 
improbable a priori. Changes have been found which would 
indicate a mild degree of irritation, which had spread by 
contiguity from the inflamed joint. 3. Reflex theory. 
This has Charcot for its especial champion but is as yet 
wholly problematical. In Kahane's opinion a combination 
of various factors is usually at work in the most of these 
cases. ( Wien. Med. Presse, No. 50, 1892.) 

G. J. KAUMHEIMER. 



Sensorial Allochiria. — Dr. F. Bosc (Rev. Internat. de 
Biblio. Med. Jan. 25) concludes that allochiria exists every 
time the patient errs as to the side whence an impression is 
received. Allochiria may exist in all sensations. Allochiria is a 
simple phenomenon which may accompany disorders ordin- 
arily unilateral or more or less pronounced on one side. It 
is not properly speaking a symptom. It does not depend 
directly on a lesion but upon such a distribution of it as 
may cause a change in the ordinary progress of sensation. 
Several causes may produce allochiria. Among the neurotics 
(Bosc's "pure hysterics'') it may result from suggestion or 
spontaneously. Allochiria from cerebral lesions may be of 
two types, cerebral or medullary, in the first case it occurs 
from reception with lesions ; in the second case it results 
from transmission. These divisions are, however, factitious. 
In one allochiria is even the cause of deviation and may be 
either medullary or cerebral. In the first case the deviation 
results from one side or the other of the spinal cord. In the 
other from one hemisphere to the other. But whatever be the 
seat of the lesion the result is the same. Perception of the 
sensation by the hemisphere ,to which it is not normally 
directed. Such passage of sensation from one hemisphere 
to another proves that there are communications between 
the symmetrical parts of the cord and brain. Clinical and 
imperfect anatomical investigations demonstrate such means 
of communication in the cord. The corpus callosum serves 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 309 

the purpose in the brain. True allochiria must be distin- 
guished from false allochiria due to partial sensory commu- 
nication to the brain. 

J. G. KIERNAN. 

Allochiria. — Bosc relates the following case. Man, aged 
42. Had neurotic family history ; personal history of 
alcoholic excesses; radials atheromatous ; myotatic irritabil- 
ity exaggerated; pronounced mental enfeeblement; increas- 
ing dementia the only noteworthy symptom, until left hemi- 
paresis without loss of consciousness occurred. Tongue and 
lower half of face were implicated as well as limbs. Perception 
of stimuli applied to any part of left half of body greatly 
retarded and localization of stimulus impaired. Motor 
paralysis complete in left limbs and left half of face ; 
articulation difficult; vocal timbre altered. On applying 
painful stimulus to left arm, patient gesticulated as if suffer- 
ing, quickly withdrew right arm and complained of pain in 
it at a part corresponding to the point of contact on the left 
arm and of acute cephalalgia. Analogous effects produced 
by pricking left lower limb, in addition thereto painful 
stimulus applied to left thigh sometimes referred to right 
leg and arm. Whenever left side of trunk was pricked 
patient cried out with pain in head and rubbed sternal region. 
Thermal stimuli only perceived as pain and were transferred 
to right side. Cutaneous sensibility of latter side unimpaired. 
Visual acuity and audition diminished on left side. 
Terminal coma set in three or four days later. Account of 
necropsy not given. This condition in which sensory 
stimulus received on one side of the body is referred to the 
opposite side was described by Obersteiner in 1881. (Brit. 
Med. Jour., Dec. 31, 1892.) 

B. M. CAPITES. 

Tetany as a Sequel of Puerperal EcxAMPSiA.-Reported 
by Dr. Wheaton. — Labor normal, except convulsions which 
followed expulsion of placenta, 13 attacks in four hours. 
Patient comatose, respiration rapid and irregular, pulse 150, 
feeble but incompressible. Wet cuppings applied to loins 
and J pint of blood removed ; J grain hydrochlorate of 
pilocarpine hypodermically; 20 grains choral, 1 drachm 
bromide of potassium per rectum. Cupping and pilocarpine 
injection repeated in an hour; profuse diaphoresis occurred, 
improvement commenced. Liquor ammoniae acetatis, 2 
drachms every two hours was administered, also a purge and 



.310 neurological. [March-June, 

enema. Third day — still unconscious; spasmodic attacks 
of rigidity of limbs noticed ; pressure caused increased 
rigidity. This tetanic condition continued three days, 
gradually disappeared; consciousness returned; in three 
weeks convalescence complete. Tetany may be regarded as 
result of profound exhaustion of higher motor centers of 
cerebral cortex, whereby restraining influence is withdrawn 
from a lower stratum of cells, which thus come into action 
without regulation from higher centres. In case in point 
exhaustion of higher centres was due to repeated convulsions 
and its intensity marked by the long period of unconscious- 
ness and absence of voluntary movement; also by the 
persistent high temperature (102°) which was probably due 
to unregulated action of lower heat-producing centers owing 
to exhaustion of higher controlling one. No treatment was 
ordered for the tetany except quinine and iron ; being essen- 
tially a symptom of deficient action of nervous centres 
it required tonic treatment. {Lancet, Jan. 21, 1893.) 



Tetany in C O-Poisoning. — Dr. A. Voss reports the case 
of a boy, 12 years old, who was asphyxiated by coal gas, and 
who presented a typical picture of tetany, including mechan- 
ical hyperexcitability of the muscles, trismus and facial 
spasm. Death took place by involvement of the muscles of 
respiration. Autopsy showed only a chronic intestinal 
catarrh. Tetanv following various intoxications has been 
noticed before, as after ergotin, alcohol or chloroform poison- 
ing. Frankl-Hochwart says in regard to prognosis : "The 
prognosis in children in whom tetany occurs during the 
course of other affections is not at all good. Intestinal 
troubles are most frequently met with." [Deutsche Med. 
Wochmschr., No. 40, 1892.) 

G. J. KAUMHEIMEB. 

The " Tic " Disease. — Dr. Chabbert concludes (Arch, de 
Neur., Jan., 1893) that under this title are comprehended 
not only movements of generalized nature, but also cases in 
which the spasms are localized. These last may originate in 
traumatism as well as heredity and may give rise to coprolalia 
(foul speech) or to " tics " of thought. In all heredity plays 
the principal part. It may be direct or similar or collateral 
and transformed. To the vesanias may be added as 
hereditary causes, alcholism and even brain diseases. "Tic" 
disease may occur in early youth (4, 6 and 9 years) but 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 311 

most often is post-pubertal. Its period of evolution varies. 
The movements due to it are rapid, systematized, coordinate 
and arhythmic. Echolalia, echokinesia, coprolalia and 
thought "ties" may be found united in the same subject but 
these are usually isolated. Echolalia is the repetition of poly- 
syllabic words clearly articulated. Echokinesia is the 
habitual repetition of movements familiar to the patient in 
connection with other words. They may occur alone or 
follow the words. Coprolalia may also accompany the 
movements or replace them. Often the will can check these. 

J. G. KIERNAN. 



Urinary Toxicity and Epilepsy. — Drs.Voisir and Peron 
conclude that an auto-intoxication, shown in variations in 
urinary toxicity, (Arch, de Neur., Jan., 1893) has an intimate 
relation to epileptic explosions. This view was enunciated 
br Meynert about two decades ago to explain the epileptic 
states. 

J. G. KIERNAN. 

Case of Alternate Hemianaesthesia. — Cases of alter- 
nating paralysis are not uncommon, but cases of alternating 
hemianaesthesia are sufficiently rare to warrant Dr. M. 
Allen Starr in presenting one which recently came under 
his observation. A policeman, previously healthy, awoke 
in the night and found himself paralyzed on the right side ; 
subsequent recollections faulty, some fever, delirious, pains 
in head, sleepless, recovered sufficiently in three weeks to 
get up. Two months later appeared at clinic, walked 
without trace of paralysis, but not steady, afraid of losing 
balance; power slightly greater on right side, knee jerks 
exaggerated, no ankle clonus. Tactile sensibility about same 
on both sides of body, slightest touch of cotton immediately 
perceived and accurately located, but a difference in the 
sensation perceived on left side of face and right limbs from 
that on corresponding opposite sides. A needle may be 
thrust one-half inch into this area of alternate hemianalgesia 
without sensation of pain, though contact of needle is felt. 
A felon had run its course on the thumb of analgesic side 
and no pain experienced. Case was diagnosed as due to 
haemorrhage into pons, because of sudden occurrence of 
symptoms, their considerable extent at first and gradual 
disappearance, absence of heart disease and specific history 
tending to exclude embolism and thrombosis. From a 



312 neurological. [March -June, 

study of anaesthesias in 26 cases, Prof. Starr draws 
following conclusions: 1. If in any case anaesthesia of 
one side of face occurs (not due to neuritis of trigeminus or 
cortical lesion), lesion lies in medulla or pons, in outer 
third of formatio reticularis ; if situated high up (cephalad) 
in pons it will be on opposite side to anaesthesia, if situated 
low down (caudad) in pons or medulla, it will be on same 
side as ansesthesia. 2. If anaesthesia of limbs occurs (not 
due to cerebral lesion) lesion lies in medulla or pons, in 
inner two-thirds of formatio reticularis and on side opposite 
to anaesthesia, or in spinal cord. 3. If one side of face 
and limbs of opposite side are anaesthetic, lesion affects 
entire lateral extent of formatio reticularis and lies in 
medulla or in pons below point of union of ascending and 
decending roots of fifth nerve. 4. If face and limbs of 
same side, then lesion lies in brain at a point higher than 
junction of ascending and decending roots of fifth nerve in 
pons. It may involve entire formatio reticularis in upper 
pons or crus cerebri ; it may be situated in posterior part of 
internal capsule ; it may lie in centrum ovale, destroying 
radiation of sensory fibres from internal capsule ; it may 
be in sensory area of cortex in which all these tracts 
terminate. {Med. Record, Feb. 11.) 



The Consideration of the Knee Jerk Symptom. — Dr. 
R. M. Phelps gives the result of his investigation in an 
article in the Northwestern Lancet of December 1st. He 
summarizes the result of his investigation as follows : We 
have, in a hasty way, tried to indicate the leading points of 
significance in the knee jerk symptom. In the following 
table we have grouped into tabular form the varia- 
tions here considered. In health: Absent in rare cases — 
never was present in these cases; sluggish in a good 
many — no cause known ; exaggerated in a very few ; 
seems to diminish in old age. Exaggeration of reflex: In 
neurasthenia — moderately ; in chronic alcoholism — moder- 
ately to excessively ; in general paresis — extremely so in 29 
out of 54 cases ; in epilepsy — in 60 per cent, of cases 
(Zerner). [My own cases about normal.] In spastic spinal 
paralysis — typically and extremely exaggerated ; in multiple 
sclerosis — usually if lateral columns are affected (Bramwell); 
in tetanus, strychnine poisoning, etc. (Jamieson); in hysteria 
— 20 per cent, of cases have ankle clonus (Ziehen). Absent 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 313 

or diminished: In locomotor ataxia — absent, with rare 
exception, usually lost early; in general paresis — absent in 
12 cases out of 54 noted ; in peripheral neuritis — diminished 
or lost ; in myelitis — usually modified or abolished (Ranney); 
in spinal meningitis — usually lost, unless lumbar region be 
unimpaired ; in diabetes — sometimes lost ; in cerebellar 
lesions (Ferguson). Unequal: After apoplexy, also emboli 
or other lesions ; injury to hip or to nerve in leg — possibly ;. 
in general paresis — in 12 out of 54; in other insanities — with 
obscure meaning; possibly from rare localized injuries to cord. 
In conclusion, then, what have we found? We have found the 
knee jerk in healthy people differing greatly, occasionally 
being found completely absent, and occasionally extremely 
exaggerated. We have also found that it varies in the 
same person with all strong sensations and emotions. This 
is somewhat discouraging at the outset. Further study, 
however, shows it to be fairly steady in the same person, if 
healthy, and that any change in it is significant, if the 
constant variation from normal is not; also, that the 
extremes of variation are almost invariably of significance 
in either case, that significance to be interpreted only by 
the context furnished by the accompanying symptoms. 
{Minnesota Hospital Bulletin.) 



Varieties of Vertigo. — Dr. Miles speaks of five kinds of 
vertigo. 1. Vertigo dependent upon intracranial disease, 
chiefly tumor and pachymeningitis, not including the 
disturbances of equilibrium arising from disease of cere- 
bellum or corpora quadrigemia. Most frequent general 
symptoms, headache, nausea or vomiting and vertigo. 
Most cases of brain tumor originate in membranes of this 
viscus ; the trigeminal nerve has wide distribution in dura ;, 
and intense localized irritation of its branches gives rise 
directly to pain and indirectly to nausea, vomiting and 
vertigo. 2. Ocular vertigo, most commonly due to serious 
disorders of refraction, to paresis or spasm of the ocular 
muscles, or to excessive retinal irritation. Partial tenotomies 
and exact corrections or recorrections with glasses have been 
found efficient. 3. Vertigo, due to disease of bloodvessels, 
as arterial sclerosis from alcohol, syphilis, gout, old age, etc. 
Diagnosis of these cases is to be made by excluding carefully 
ear, brain, eye, severe local disease anywhere, etc., but 
chiefly by careful examination for arterial or arterio- 



314 neurological. [March-June, 

capillary fibrosis and accompanying conditions of heart, kid- 
neys, liver and other organs. Reedy, resisting arteries, 
excessive arcus senilis, changes in pulse-rate, reduplicated or 
changing cardiac sounds will be present. 4. Vertigo which 
has its source in state of blood, as anaemia or hyperaemia, 
lithaemia, and a large variety of toxaemias and from direct 
action of drugs and poisons. 5. Vertigo dependent upon 
intense irritation reflected to labyrinth or brain from more 
or less distant regions of the body — commonly classed as 
nasal, pharyngeal, laryngeal, gastric, intestinal, hepatic, 
uterine, ovarian, etc. The reflex origin of these vertigos 
is often doubtful; they are more probably due to a toxic 
state of the blood, which is produced in various ways. — 
(Medical Record, Feb. 18. '93.) 



Migraine. — In The Lancet of Jan. 14, Dr. A. Wallace de- 
scribes a personal experience of this malady extending over 
sixty years. This diathesis is gouty, although he has never 
had an acute attack. In most cases of the disease Dr. Wal- 
lace lays down the proposition that "migraine is due to de- 
fective or insufficient excretion, partly of the liver but 
mainly of the kidney." Patients are sallow, bowels are 
costive, urine before and during attack is limpid with low 
•specific gravity, and after attack highly colored by lithates. 
Previous to attack patients generally complain of backache 
and are indisposed to exertion and irritable: afterwards 
are cheerful and energetic. Two opposite conditions 
may cause an attack: (1.) where abdominal and eliminating 
organs are less able to perform work than usual, and (2.) 
where a greater onus is thrown upon these organs than they 
•can for the time being perform. Under cause 1 are classed 
check of skin action, exposure to cold, vitiated atmosphere, 
tobacco, malt liquors, tea and other articles acting as econo- 
mizers, insufficient inhibition of fluid, fatigue, etc. Under 
cause 2 may be mentioned over-exertion of body and mind, 
over eating, or indulgence in saccharine or fatty foods, etc. 
Prevention may be secured by properly exercising mind 
and body, and giving careful attention to dietary and regu- 
larity of living. A tumbler or two of hot water containing 
mineral salts taken in the morning while dressing is bene- 
ficial. To abort an attack dietary should be spare and con- 
tain much fluid. Slight attacks often yield to caffeine or 
bromide of potassium. 



1893.] PATHOLOGY AHD SYMPTOMATOLOGY. 315 

OXALUBIA AND ITS RELATIONS 70 CERTAIN FORMS OF 

Nervous Disease is the title of a paper read by Dr. I. 

Adler before the 2S». Y. Neurological Society. Jan. 3, in 
which he stated that oxaluria, as an independent type of 
disease, does not exist. Most veg >le food-, dn oxalic 

acid, and nearly all taken into the system reappears in the 
urine, some, perhaps, in the faeces. It is also probable that 
the acid may originate in the course of normal metabolic 
changes. In examining urine for oxalic acid it is of the 
utmost importance to consider its other ingredients as well, 
particularly urea and uric acid. In di- ssing the paper 
Dr. Herter said he was not prepared to believe there was no 
such thing as pathological oxaluria, but was inclined to 
think that in cases of defective digestion the carbo-hydn 
are transformed into oxalic acid. Dr. Heitzman also dis- 
agreed with Dr. Adler and felt convinced that there is a 
condition of the system wherein the amount of oxalic 
acid excreted by the urine is far in excess of that taken in 
with the food. Dr. Rockwell was interested in noting the 
frequency with which oxaia - crystals had 

appeared in the urine of certain neurasthenic cases ssoci- 
ated with disordered heart action. In summing up Dr. 
Starr stated that we cannot study neurasthenic conditions 
carefully without reaching the conclusions that the trouble 
lies in the chemistry of nutrition and that the si tern Mite in 
Dr. Adler's paper, based upon careful quantitative analysis 
of the urine, should be regarded as very valuable. (New 
York Med. Jour., Jan. 28.) 

Alcoholism. — Dr. E. Schmid summarizes h >ns 

and reflections upon alcoholism in a paper read before the 
New York State Med. Ass'n, Nov. 1892. The intoxicating 
part of alcoholic beverages is ethyl-alcohol and in ten g] asses 
of beer for example, there is half a glass of this poison. This 
substance enters the blood and is carried to the various or- 
gans, first to the brain. It is thought that here the action 
is molecular in character. When protracted indulgence is 
practiced the chemical affinities of the nerve elements are 
paralyzed, and finally, their life destroyed. The action of 
the heart is quickened and tension of arterial walls Lessen 
The blood is not changed. Small doses of alcohol stimulate 
secretion of gastric juice, but large amounts delay or actually 
suspend It. Competent observers maintain that any quan- 
tity taken during digestion produces this effect. Tissue 



316 neurological. [March-June, 

change is decreased by alcohol ; excretion of carbonic acid 
lessened ; large doses lower temperature of body ; great ex- 
penditure of warmth is caused by dilatation of vessels of 
skin, paralysis of muscles, and by reduction of the oxidizing 
processes in the tissues, Alcohol only transiently benumbs 
feelings of weariness and relaxation surely follows. It is, 
therefore, only indicated medicinally in that pathologic con- 
dition approaching collapse with frequent and small pulse. 
Long continued doses in milk or water given as a tonic 
cause chronic irritation of the mucous membrane of the 
stomach, and often cirrhosis of the liver. In children we 
notice clearly how powerfully alcohol attacks the nervous 
system, not infrequently producing convulsions, epilepsy or 
chorea. Imbecility can often be traced to the imbibing of 
alcohol by the nursing mother, but the worst effect upon 
children is paralysis of the moral power. Heredity entails 
love of drink upon the offspring of intemperate parents or, 
frequently they are injured mentally. Plutarch said, -'Ebrii 
gignuntebrios," and Darwin states that diseases inherited from 
drunkards descend to the third and fourth generations, un- 
til, finally, the family dies out. A specialist in childrens' 
diseases observed ten families of drinkers and ten of tem- 
perate parents for a period of twelve years. The former 
produced 57 children of whom but ten showed normal dev- 
elopment of body and mind : of 61 children of the temper- 
ate families 50 were normal. Dr. Schmid closes his paper 
by urging that steps be taken petitioning the legislature to 
pass laws for the legal commitment of drunkards, and erec- 
tion of suitable buildings dedicated to their restoration. — 
{Medical News, Jan. 28.) 

Relation of Genital Irritation to Nervous and Men- 
tal Diseases. — In a paper read by Dr. L. C. Gray before the 
N. Y. Medical Society, he maintains that there is no proof 
that genital irritation is capable of causing any organic 
disease of the nervous system, but may act as an exciting 
or aggravating factor. In mental diseases relief of genital 
irritation has, in his opinion, proved a much more valuable 
method of treatment than generally accredited. Of the two 
classes of mental diseases — organic insanities and psycho- 
neuroses, only in latter relief of genital irritation is of value. 
His conclusions were as follows: 1. That there is no proof 
that genital irritation can cause nervous or mental disease, 
except in the predisposed individual. 2. That proof is not 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 317 

yet absolute that genital irritation can produce nervous or 
mental disease, even in predisposed individual. 3. That 
there is undoubted proof that relief of genital disease will 
often relieve certain nervous diseases, such as migraine, 
hysteria, epilepsy, simple nervousness and hallucinatory 
insanity. — [Med. Record.) 



Intermittent Disturbance of Locomotion due to 
Arterial Disease. — Dr. A. Elzholz reports the case of a 
man, aged 57, who had chronic nephritis and sclerosis of all 
accessible arteries. He walked with feet wide apart, jump- 
ing and swaying. After walking for some time, tremor of 
the legs set in. Sensation and the motor strength of the 
entremities were intact. Autopsy showed arterio -sclerosis of 
the muscular arteries of the lower extremities. Another 
patient was sixty years old, and claimed to have had his 
trouble for over 20 years. It consisted in rapid fatigue of 
the muscles of the extremities, which were flabby and 
atrophic. All accessible arteries were convoluted and hard. 
Co-ordination and reflexes were normal, motor power much 
reduced. These symptoms were less after prolonged rest. 
Elzholz attributes these troubles to the endarteritic process. 
Charcot sees in this intermittent lameness the prodome of 
gangrene, either senile or diabetic. The only palliative is 
rest. ( Wien. Med. Presse, No. 40, 1892. ) 

G. J. KAUMHEIMER. 

Symmetrical Gangrene. — Kornfeld read a paper on this 
subject before the Vienna Medical Club. He would restrict 
the use of this term to such cases where absolutely no other 
demonstrable etiological factor exists and where we can rea- 
sonably assume a tropho-neuroses as the cause. It cannot 
be applied to accidentally symmetrical gangrene due to car- 
diac, renal or vascular lesions, thrombosis, severe infections, 
•disturbances of haematopoiesis, ergotism or acute decubitus. 
For this reason a number of the reported cases must be ex- 
cluded. He then reports a case of advanced tabes. The 
pulse in the abdominal aorta and vessels of the lower extrem- 
ities was full and visible to the eye, in the upper extremities 
it was small and thready. On admission the matrix of the 
nails and an area J cm. around them on the first four toes of 
the right foot were dark blue, shrivelled and cold. On the 
left foot this was the case on the great toe, the others were 
'Cyanosed and blue. Death on third day in hospital. 



318 neurological. [March-June, 

Autopsy showed degeneration of the posterior columns, and 
bilateral peroneal neuritis. There was no other lesion 
which would explain the gangrene or the difference in vas- 
cular tension. — ( Wien. Med. Presse, Nos. 50 and 51, 1892.) 

G. J. KAUMHEIMEB. 

Secondary Malignant Neuroma. — Prof. C. Garre, from 
an exhaustive study of this subject, reaches the following 
conclusions : Multiple neurofibromas, as phenomena of a 
congenital elephantiasis neuromatodes, show a remarkable 
disposition to sarcomatous degeneration. This occurs in at 
least one-eighth of all cases. The cause of this must probably 
be sought in the congenital pathological condition of the 
nervous system, neuro-fibromatosis, as it is an integral 
property of this affection to develop into sarcoma by means 
of cellular proliferation. Between the n euro-fibroma and 
the sarcoma of the nerves can be found a large number of 
transition forms, so that the exact boundary between 
malignancy and benignity cannot be accurately drawn, 
either clinically or histologically. The neuro-fibroma may 
become sarcomatous at any stage. Among the predisposing 
causes traumatism probably has the first place, leading to 
increased proliferation of cells ; injuries of various kinds, 
insignificant irritations frequently repeated, or operations 
may start the abnormal development. The clinical course 
of secondary malignant neuroma differs considerably from 
that of primary neurosarcoma. The latter do not differ 
from the fascial sarcoma except in localization, they rapidly 
invade the surrounding tissues and cause early and exten- 
sive metastases. The neurosarcomas arising on the basis of 
an elephantiasis congenita neuromatodes usually retains its 
fibrous capsule for a long time, its recidivation is usually 
local and multiple and only in the last stage does it infiltrate 
the surrounding tissues and cause metastases. Virchow's 
recurring neuromas with local malignity are a variety of 
the secondary malignant neuromas; the local malignity is 
a transition stage. The histological character is most often 
that of the spindiecelled fibrosarcoma. Degenerative 
changes, leading to the formation of cysts and cavities, are 
of very frequent and early occurrence. A formation of 
young nervefibrils, such as Krause claims for malignant 
sarcoma, takes place, but seldom. The nerve fibres entering 
the tumor disappears very soon. Neurosarcoma may 
assume the character of a teratoma by the participation of 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 319 

heteroplastic elements (in Garre s case ciliated epithelium) 
in the formation of the tumor. ( Wien. Med. Blatt., No. 47 

10 OU, lOoZ.) G j. KAUMHEIMER, 

Diaphragmatic Neuralgia and Spasm caused by In- 
fluenza. — Dr. Ferd. Kapper reports the case of an officer to 
whom he was called at the time the epidemic was at its 
acme. Among other things he complained of pain at the lower 
edge of the chest all along the insertion of the diaphragm, 
as well as in both sides of the neck, radiating toward the 
shoulders and back of the neck. All these parts were pain- 
ful to the touch. The respiration was dyspnoeic, painful and 
superficial and moderate hiccough was present. The next 
day hiccough had increased, and became especially annoy- 
ing when the voice was used. It was accompanied occasion- 
ally by yawning or vomiting. On the morning of the 
second day the temperature had fallen. The hiccough was 
intense, 100 per minute, with occasional intervals of 10 
minutes. On the fifth day the frequency had decreased to 
60 per minute with longer intervals of rest. The spasm 
gradually became slower, the intervals of rest longer, and 
the pains at the insertion of the diaphragm and along the 
course of the phrenic nerves less and disappeared at the end 
of two weeks. The Pfeiffer-Canon bacillus was found in 
enormous numbers in the sputum. Methodical counting, 
impeded expiration, ice, compression of the thorax, pressure 
on the phrenic nerves, as well as narcotics, were tried in vain. 
Epispastics and hot applications gave some relief. Cure 
resulted from faradization of the phrenic nerves, the 
diaphragm and the epigastrium after the administration of 
antipyrin. An explanation of the pathological process is 
not possible, but the connection between the phrenic pain 
and spasm and the influenza is undoubted. (Wien. Med. 
Wochenschr., No. 37, 1892.) 

G. J. KAUMHEIMER. 

A Review of the Pathology of Puerperal Eclampsia. — 
Dr. Moser thinks that one of the principal reasons why the 
morbid anatomy of eclampsia, and the etiological deductions 
therefrom, have given rise to so much discussion, is because 
the post mortem appearances differ in almost every cadaver. 
We are endeavoring to find the pathology of a disease char- 
acterized clinically by convulsions and coma occuring in 
pregnant women. The author is inclined to believe that 



320 neurological. [March-June, 

there are several etiological factors concerned in its causa- 
tion ; that it is not a distinct disease ; that it has no charac- 
teristic symptomatology and pathology. The most constant 
pathological lesion is the presence of fat in the pulmonary 
circulation. Virchow regards these emboli, which occur in 
such quantities as to interfere with the pulmonary circula- 
tion, as the cause of the oedema which is such a frequent ac- 
companiment. In some cases under observation in Vir- 
chow's laboratory the characteristic " sausage-shaped plugs " 
of fat filling the lumen of the vessels could be easily dem- 
onstrated under the microscope. In no case were they ab- 
sent. The author believes with Virchow that they are the 
effect produced by the convulsion. He thinks that the 
pathological changes give no clue to its etiology, and that 
we should look for more than one etiological factor. — (Med. 
Record, Mch. 25, 1893.) 

B. M. CAPLBS. 

On Paroxysmal Tachycardia and Its Relation to 
Graves' Disease. — Dr. Dill has notes of a number of cases 
in the Lancet of Feb. 4th. He thinks the patient is usually 
extremely nervous ; apt to suffer from digestive troubles ; 
almost invariably incapable of work. Undue strain of body 
or mind, rheumatism, and syphilis are the antecedent con- 
ditions of most of the recorded cases. Many have no 
previous history. In some instances the paroxysmal state 
of tachycardia had passed into a persistent one. He 
describes another class of cases, arising very often from 
similar causes and following a similar course, in which the 
tachycardia is persistent, but with paroxysms of palpitation 
and in which the persistent tachycardia during the intervals 
between the paroxysms may not be subjectively evident to 
the patient. To distinguish these two classes of paroxysmal 
tachycardia he adopts the names "remittent" and "inter- 
mittent." Describes the third class of cases presenting 
precisely the same symptoms, which are evidently atypical 
cases of Graves' disease. The only absolute constant symp- 
tom of Graves' disease is tachycardia, but Charcot is 
authority for the fact that in some cases of Graves' disease 
the tachycardia is paroxysmal and intermittent. The fol- 
lowing is a note of a case : Patient had severe fall upon left 
side. For past twelve months unable to work. Complained 
of violent paroxysms of palpitation which prostrated him 
completely. Heart very rapid in the interval, although it 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 321 

gave him little discomfort. Was extremely nervous; 
wasted considerably, and suffered from flatulent dyspepsia. 
Arterial tension increased. For eight months rate of pulse 
between the paroxysms averaged 135.5, never to author's 
knowledge under 120. Gradually declined as he got better 
until it became normal. Suffers from occasional paroxysms 
of palpitation. Among other theories the pathology has 
been attributed to recurrent irritation of the cervical 
sympathetic, to paresis of the vagus, to lesion of the 
myocardium or of the cardiac nerves or ganglia and to a 
central nervous lesion. The author thinks the last to be 
the correct explanation. Digitalis and strophanthus appear 
to have no effect. Quinine, iron, arsenic and belladonna 
are very unreliable, and the usual nerve sedatives and 
stimulants do not appreciably influence the course of the 
disease. He thinks the treatment to which attention should 
be directed is complete rest from work or strain both of 
body and mind, pleasant and unexcitable surroundings. 
General health must be carefullv watched ; intercurrent 
discomforts treated as they arise. 

B. M. CAPLES. 



Erythromelalgia. — What may almost be considered a 
symposium upon this very rare disease recently took place at 
the Charite Society in Berlin, three cases being brought for- 
ward by Gerhardt, Senator and Bernhardt. As the patient 
introduced by the first was the most recent, the case may be 
given in fuller detail. A seamstress, aged 44, had formerly 
suffered from palpitation and fainting. In the night of 
March 21 she was suddenly seized with very severe pains in 
hands and feet, which, notwithstanding different kinds of 
treatment, continued until the end of June, when the 
patient was shown. Simultaneous with pain, occurred an 
extraordinary redness of the fingers and toes, affecting all 
these except the left thumb, which remained free. Move- 
ment was very unpleasant to the patient, and she mentioned 
that such an act as cutting the nail caused severe pain, and 
contact of the toes with the bedclothes was so painful that 
she desired to lie under a cradle. All the various remedies 
were tried. Beginning with arsenic, a slow improvement 
took place, but when having a galvanic hand bath, a severe 
attack of pain came on, and this time the left thumb was 
involved. Morphine injections and antipyrin relieved the 
discomfort. Later on, in another attack, there was pain in 



322 neurological. [March-June, 

the tongue and disturbance of speech. Since then the affec- 
tion had improved very much in the arms, less so in the 
lower extremities. The terminal phalanges were now some- 
what thickened, but this was not so much due to the bulg- 
ing forward of the matrix of the nail as to thickening of the 
edge of the skin on the nail. The finger pulp was much 
more thickened in relation to the nail-bed, and showed a 
changing red appearance, which became almost bluish-red 
during the attacks of pain. The state of the nutrition was 
not altogether favorable ; and the examination of sensibility 
showed that heat and cold were slowly perceived, and that 
there was a slight degree of diminution of sensation. The 
secretion of sweat was increased in the affected parts. 

The case shown by Professor Senator was a man, 44 years 
old, hitherto healthy, who was suddenly taken ill with 
neuralgic pains and weakness in the arms, and then in the 
feet, on which an almost symmetrical erythematous redness 
of the skin of these parts supervened. The pain gradually 
ceased, while the erythema remained in varying degree and 
got worse during two summers, coincident once with in- 
creased turgescence of the hands. Upon the reddened 
places over the individual finger-joints reddish nodules 
showed themselves during the course of the affection, of 
which one after another disappeared only to appear in other 
places. Dr. Bernhardt's case was an unmarried lady, 50 years 
of age, who had suffered since 1887 from pain, redness, and 
swelling in the hands and feet. In contrast to the others, 
she was worse in cold weather. There was disturbance of sen- 
sation. Ery thro melalgia was first described as an independent 
disease by Dr. Weir Mitchell in 1872, from six cases observed 
by himself and five reported by Graves, Paget, and others. 
He showed that it chiefly affected men, and began usually 
with slight febrile symptoms, and severe pain in the feet, 
more rarely in the hands. It was increased by the Upright 
position and by warmth, and was therefore worse in sum- 
mer ; the horizontal position and cold relieved it. After a 
time a congestive redness of the affected parts set in, some- 
times very marked, with visible swelling of the veins, pul- 
sation of the arteries, and increased temperature in the 
affected parts. The disease runs a very chronic course for 
many years, with alternating improvement and relapse. Its 
actual termination is not yet sufficiently known, as the 
patients have gone from under observation, and the affection 
is so rare that few opportunities are given of watching the 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 323 

case to the end. In 1880, Lannois was able to add only five 
cases to the eleven reported by Dr. Weir Mitchell ; and 
within the last twelve years only four more have been 
added. The redness and swelling depend upon a hyperemia 
from active dilatation of the blood vessels, a process depend- 
ing on paralysis of the vaso-constrictor nerves — an angio- 
paralysis, belonging therefore to the class of vaso-motor 
neuroses. Anatomically it resembles chronic hyperemia or 
erythema, and it is probable that these cases were classed 
under the term chronic local or diffuse habitual erythema. 
Its marked symmetry and other points suggest its central 
origin. It is the opposite condition to that described by 
Eaynaud under the name of symmetrical local asphyxia of 
the extremities, or local gangrene, where there is ischsernia 
due to spasm of the vessels. This is curiously enough com- 
moner in women than in men, the reverse of ervthromelal- 
gia. The treatment is unsatisfactory, although there is a 
case recorded by Duchenneof improvement after the faradic 
current. (Berlin. Klin. Wochenschr., No. 45, 1892, The Prac- 
titioner, Dec. 1892.) 

Neurotic Eczema. — Dr. IBarham reports the case of a 
female 55 years of age who had an eruption situated on the 
lower two thirds of the fore arms and legs. It was rather 
more distinctly shown on the extensor than on flexor sur- 
faces and on upper surfaces of hands and feet is sy metrical. 
The eruption is characterized by patches, circular or round 
in shape, composed of vesicles or papules with intervals of 
healthful skin. Patches show all stages of inflammation from 
unbroken vesicles and papules to raw exuding surfaces or 
infiltrated and covered with fine crusts or even scales. Each 
patch is limited to the line of papules or vesicles and the 
distinction befween healthy and diseased skin is sharp and 
absolute. At all stages of the disease the pruritus has been 
intense. In the second case patient was nervous and irrit- 
able, suffered from constipation ; eruption located on dorsal 
and interdigital spaces of fingers and on back of each wrist. 
Between fingers skin is sodden but inflammation is sharply 
defined at edge of patch. On back of each wrist is a large 
sharply defined patch, moist and inflamed, the edges com- 
posed of vesicles and papules. Patch is infiltrated and the 
pruritus is excessive. Several other cases are reported and 
in all these the most striking peculiarity is the symmetrical 
disposition of the lesions; in many cases the symmetry isab- 



324 neurological. [March-June, 

solute, in others approximate but in every case correspond- 
ing parts of the body on each side are found to be affected. 
The eruption tends to attack localities not as a rule liable to 
eczema in its primary state, that is, the extensor surfaces. 
Arrangement of lesions differs markedly from that usually 
observed in eczema. The lesions are not scattered indis- 
criminately over affected area but are grouped into patches 
more or less circular. The periphery remains distinct, 
sharply denned and absolute at all stages ; spread of erup- 
tion never effected by gradual extension of area of diseased 
patches but by formation of new lesions or patches in every 
respect retaining characteristics of older ones. Dissolution 
of patch is accomplished not by gradual shrinking of the 
diseased area but by degrees of inflammation. Original area 
remains same in extent, eruption has tendency to frequent 
relapses. The pruritus is most intense. Previous mental 
worry or nervous exhaustion of longer or shorter duration, 
functional irregularities, chronic constipation, exposure to 
heat and cold were noted in most of these cases. The author 
thinks the eruption the result of reflex irritation, whether 
this irritation is an actual inflammation he is not prepared 
to state, but in results it is practically the same. In regard 
to the sensory nerves their predisposition is shown by the 
intense itching in the affected area. He concludes that 
there is a variety of eczema due to a nervous disturbance 
which may be recognized by the following characteristics: 
grouping of lesions in circumscribed patches sharply separ- 
ated from adjoining healthy skin; symmetry of eruption; 
preferences for extensor surfaces of extremities; absence of 
peripheral spreading or contraction of the separated patches ; 
that the nervous disturbance is a perverted functional action 
of "trophic centers" in the cord; and probably in some 
cases a peripheral neuritus; that reflex irritation from various 
functional irregularities, mental anxiety, neurasthenia, etc., 
are important predisposing factors. — (Medical News, March 
25, 1893.) 

Rhythmical Rocking Movements in Children. — At a 
meeting of the Clinical Society of London, Dr. Hadden 
exhibited two cases of rhythmical rocking movements in 
children. One was an intelligent little girl of three years 
and nine months who had swaying movements of the trunk 
and lower limbs when standing or walking. Movements 
dated from the age of one year, when child was observed to 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 325 

move body from side to side when piano was played, 
apparently keeping time. The second was an intelligent 
female child aged one year and nine months, who had 
rhythmical movements of alternate flexion and extension of 
the lower part of the spine with flexion and extension at the 
hips and knee joints. Movements had been observed for 
five months and no cause for them could be ascertained. 
They were only observed when the child was sitting down. 
(Lancet, Dec. 3, '92.) 

Death by Electricity. — Dr. Clowes reports the following 
case : An employe of an electrical supply company was 
engaged in making connection and while working in the 
surface box was observed to fall to one side as if in a fit. 
Left hand was found attached to the connecting wire ; wire 
immediately broken and when released gave a loud sigh, 
fell forward, gave no further movement or sign, when seen 
five minutes later heart and respiration had stopped. The 
current was about two hundred volts. Post-mortem, the 
vessels of the scalp, meninges of the brain and brain 
substance were congested and full of liquid blood and the 
surface of the white substance when cut across presented a 
punctate appearance. The lateral sinuses were fall of liquid 
blood and the lateral ventricles contained a full amount of 
cerebro-spinal fluid. Mucous surface of larynx, trachea and 
bronchi was congested and lungs loaded with dark blood, heart 
completely empty. There was a deficiency of blood in the large 
vessels ; liver much congested and a dark red color ; spleen 
large and gorged with blood ; kidneys large and congested ; 
bladder contained 8 oz. of highly albuminous urine. A 
marked feature of the examination was the complete 
fluidity and dark color of the blood, not a clot being 
discovered in any part of the body. Blood remains fluid 
on being kept. Medulla oblongata and amido-myelin 
coagulated. (Lancet, of Dec. 3, 1892.) 



Functional Torticollis, Dependent upon Ocular Mus- 
cle Paralysis. — Nieden reports a case in which torticollis 
has been induced by paralysis or paresis of one or more 
ocular muscles and consequent diplopia. To correct the 
latter symptom the oblique position of the head is assumed 
and kept up. His patient was a lad aged 11, in whom the 
torticollis had been noticed at the age of five and had 



326 neurological. [ March- Ju ti e r 

gradually become a constant condition in spite of treatment 
by various apparatus. There was marked delect though 
not complete paralysis of left superior rectus without notice- 
able limitation of movement of left eye up and in. The e}^e 
deviated outwards and downwards and this deviation was 
said to have come on after a convulsive attack in early 
childhood. Correction of the strabismus by operative 
measures was speedily followed by improvement and 
eventually by complete cure of torticollis. (British Medical 
Journal, Dec. 31, '92.) 

Production of Cramps by Faradism. — Babinski reports 
his experience of the action of faradism in cholera, patients 
chiefly, but also in others. The cramps produced continue 
after the current is removed and present the same characters 
as those developed spontaneously. Can also be evoked in 
acute peritonitis, lead poisoning, alcoholism, peripheral 
neuritis, less frequently in tabes, spastic paraplegia, and 
functional disorders of the nervous system. The condition 
induced is considered of the nature of a true cramp and not 
analogous to the muscular stiffness in Thomsen's disease, or 
in the myotonia acquisita of Talma. (British MedicalJournal, 
Pec. 31, 1893.) 

Verminous ^Pseudo-Epilepsy. — Dr. Oirat (IS Union Med. r 
Nov. 12, 1892) reports a case of epilepsy under this title in 
which the use of a taenifuge caused cessation of the attacks, 
but some days before the expulsion of a tape worm. This- 
indicates, in Dr. Girat's opinion, that the movements of the 
worm were chief exciting factor. 

J. G. KIEBNAN. 

Cicatricial Compression of Nerves. — Charcot, (La. Trib. 
Med., Dec. 15, 1892.) reports a case in which a man who had had 
a burn in the centre of the fist presented a cicatricial compres- 
sion of the anterior branch of the cubital nerve, determining 
a remarkable dissociation of sensibility. As in syringomyelia 
tactile sensation remained intact while thermic sensibility was- 
abolished in the territory supplied by the affected nerve. 
When the cicatrix was removed by operation, thermic sensi- 
bility gradually returned. This fact shows, according to 
Charcot, that the cause of dissociation of sensibility does not 
necessarily reside in the spinal cord. This dissociation also 
exists in certain dermatoses, so that it can be said clinically 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 327 

that there exist special peripheric apparatuses for each 
mode of sensibility. The question of neuritis could not be 
raised since in a fortnight after the operation thermic sensib- 
ility was complete. Charcot would explain this dissociation 
of sensibility by the claim that touch was a more highly 
developed special sense than the thermic sense, which might 
disappear without the higher sense being affected. Gley 
could not agree with Charcot that thermic sense should be 
accepted as lower than the touch sense. All animals, even 
the amoeba, were susceptible of temperature variations. 
Charcot's claim refuted itself; the last powers acquired in 
evolution were the first lost in disease. 

J. G. KIERNAN 



Myoskism. — Durant and Klippell describe (Revue de Med., 
Oct., 1892) a neurosis differentiated from other hereditary 
neuroses by a movement to which they apply the above 
designation. This is a jerk occurring at the moment of 
voluntary movements. The symptoms of evolution of this 
new neurosis in its first period are : Onset at 30 to 35 years 
of age by gastralgias, cramps and lancinating pains in the 
lumbar regions. In the second period, myoseism, the special 
symptom of the neurosis, appears. It is characterized not by 
a trembling or an ataxia but by the repeated stoppages 
occurring in the course of muscular contractions, and 
transforming the uniform movement into a jerky state. 
Romberg's sign, fibrillary chorea, normal electrical reactions, 
jerky speech, pseudo-nystagmus (occurring only when the 
eyes move) and subjective troubles (cramps, in extremities, 
especially legs, anaesthesia) occur during this period. In the 
third period there added to these described trembling of the 
muscular masses, jerking of the tendons, great weakness, 
anaesthesia of the muscular sense and amaurosis. These 
results are based on the study of four cases in the same 
family (three brothers and one sister). The affection had 
been ascertained to be present in the mother and maternal 
aunt. 

J. G. KIERNAN. 

The Choreic Movement.— Dr. H. C. Wood has shown by 
experiment that section of the cord does not arrest choreic 
movements either on the upper or lower segments of the 
body. Other experiments lead him to conclude that there 
are either inhibitory spinal centers or that the spinal motor 



328 neurological. [March-June, 

cells are inhibited by peripheral impulses. He holds that 
quinine is a stimulant and atropine a depressant of spinal 
action. From this he assumed that if chorea is due to 
weakness of the spinal inhibitory centers quinine would 
strengthen the centers and so check the movements. Experi- 
ments upon dogs confirmed this view. He has relieved 
choreic movements in a child by cinchonizing it and in- 
tends continuing the use of the remedy to test its value. — 
{Jour. Nervous and Mental Diseases, April 1893.) 



Nervous Disturbances after Removal or Atrophy of 
Testicles. — Dr. C. H. Hughes reports several cases of 
insanity and hypochondria that have come under his observa- 
tion in which disorder resulted from removal or atrophy 
of testicles. Concerning Weiss' theory that the nervous 
disorders due to the loss of the tonic of the seminal secretion 
the author thinks there are other factors, such as the 
dyscrasic changes that made operation necessary and the 
after effects of the operation itself. {Alienist and Neurologist, 
Jan., 1893.) 

The Neuropathic Constitution, Education and Mar- 
riage in relation to Nervous Diseases. — The neuropathic 
constitution, according to the author, manifests itself by 
nervous instability and defective innervation of the organic 
functions. It checks normal development and predisposes 
to degenerative changes in nerve elements. These defects 
in the structural elements of the nervous development are 
hereditary, the predisposition being often derived from 
defective nutrition, bad habits or bad education, which have 
lowered the normal standard of health. The author con- 
demns the modern high pressure of education and 
especially the nervous tension and excitement with which 
the work of the age is carried on. Concerning marriage 
and education the author seems to imply that there should 
be some restrictions in regard to the present liberty allowed 
people in entering into the marriage relation. Concerning 
the education of children, he holds, that in place of the age 
of the child being a criterion of mental strength and 
capacity, that the child's body weight should determine this. 
When children fall below certain physical standards there 
should be a reduction from the amount of mental work 
required of them. [Medical Herald, March, '93.) 



1893.] THERAPEUTICS. 329 

THERAPEUTICS. 



The Chemico-Physiology of Sulphonal. — In The Practi- 
tioner, for Dec, 1892, Dr. W. J. Smith gives results of 
personal experiments with sulphonal made in the body of 
the dog. From these he infers that the drug does not affect 
tissue change. Three grammes, when given in complete 
solution, always yields some unaltered sulphonal in the 
urine of the dog, also in man. Jolles has found that in 
man part of the sulphonal is oxidized to sulphuric acid, but 
Dr. Smith has not detected this in the dog even after large 
doses of the drug. As but a small part of ingested sulphonal 
escapes change, the question arises, what becomes of the 
remainder? Kast states that it is eliminated in the form of 
a highly soluble organic compound, probably a sulphone 
acid, but the author's investigations do not confirm this 
conclusion. He presents two probabilities : (1.) Sulphonal 
may split in the same manner as do some of its derivatives, 
namely, the ethylsulphone group may be set free in the 
form of etbylsulphonic acid. (2.) When the ethylsulphone 
group is split oft the ethyl portion may be oxidized and then 
the very stable sulphonacetic acid would be formed. Ex- 
periments with ethylsulphuric acid demonstrate that it 
passes for the most part unaltered into the urine, the 
sulphuric acid of which is only slightly, if at all, increased 
in amount. As the potassium and sodium salts of etbyl- 
sulphonic acid are almost insoluble in absolute alcohol an 
attempt was made to recover the potassium salt from the 
alcoholic extract of evaporated urine by treating this with 
absolute alcohol. The sediment refused to crystalize, the 
extractive substances present causing it to yield a yellow, 
syrupy sulphuretted substance which could not be purified 
sufficiently for analysis. Experiments with sulphonacetic 
acid gave the same results as far as absence in increase in 
amount of sulphuric acid is concerned, but differed in that 
the salt could be easily recovered from the urine. Dr. 
Smith's final conclusion is, that if sulphonacetic acid is the 
chief product of the metamorphosis of sulphonal, its 
presence in the urine could easily be demonstrated. The 
examination, however, of a large quantity of sulphonal 
urine gave no trace of barium salt, and, consequently, 
sulphonacetic acid cannot be the principal product formed 
from sulphonal during its passage through the body of the 



330 neurological. [March- June, 

dog. The author's experiments, on the contrary, seem to 
indicate indirectly, that the sulphonal splits in the system 
so as to yield ethysulphonic acid and this t is eliminated 
unaltered in the urine. Several tables and chemical 
formulas are given in Dr. Smith's article, adding to its 
interest. 

Trional as a Hypnotic. — Brie (Neurologisches Centralblatt, 
Nov. 24, 1892.) Trional is a white powder, similar in ap- 
pearance to suphonal, sparingly soluble in cold water, more 
so in hot water, and readily soluble in alcohol and ether. It 
has a slightly bitter taste, which is not often objected to by 
patients. The dose is from one to three grammes given about 
half an hour before bedtime. Brie tried it on forty-two 
patients. There were eleven cases with mental depression, 
melancholia and conditions of hypochondria with insommia. 
The drug acted well, without bad after effects, in every case, 
producing from seven to nine hours of sleep. Four patients 
suffered from melancholia agitata. They were restless, 
moaning and crying day and night. The result was excel- 
lent; one patient required one gramme, two, two grammes, and 
one three grammes to produce sleep. There were ten cases of 
maniacal excitement in one of which the drug failed. The 
patient vomited, so the use of the drug had to be discontin- 
ued. Whether the gastric irritation was due to the trional 
or to other causes could not be determined. Other bad ef- 
fects were not noticed. In eight cases in which hallucina- 
tions were the prominent symptoms trional always proved 
satisfactory. In the remaining cases of senile dementia, or- 
ganic brain disease and paralytic imbecility the results were 
good. Trional was also used in a number of acute surgical 
cases in persons of normal mental condition, but failed to 
produce sleep. As a result of his observations the author is 
well pleased with the drug. He considers it one of the best 
of the hypnotics. He believes that it will take the place of 
sulphonal and other hypnotics because it is practically taste- 
less, is easily taken, acts quickly and seldom shows bad after 
effects. It is indicated in simple insommia as well as in 
restless and excited conditions of the insane. 

JOS. KAHN. 

Trional and Tetronal. — Dr. Mabon reports his use of 
these new hypnotics and sedatives at the Utica Insane 
Asylum. His conclusions are as follows: These new 



1893.] THERAPEUTICS. 331 

remedies both have a marked hypnotic and sedative 
action, but trionai appears to be the more service- 
able as a hypnotic for the insane. On the other hand, small 
doses of tetronal appear to give the best results as a sedative. 
As a rule, the hypnosis which is produced is calm and 
quiet and resembles very jclosely natural sleep. In a few 
instances unpleasant after effects were noted, but they did 
not continue long and were not at any time alarming. They 
do not depress the heart's action. In the majority of cases 
fifteen grains (gramme 1) of trionai given in hot milk at 
bedtime will produce sleep of from six to nine hours' dura- 
tion which is not accompanied by dreams. The time it 
takes to produce this effect, is, in favorable cases, from fifteen 
to forty-five minutes, although it may be prolonged to over 
# two hours. With tetronal it was found that generally fifteen 
grains (gramme 1) were required to obtain the same results, 
and as this remedy is twice as expensive as trionai the latter 
is to be preferred, as a rule. Both of these drugs have the 
effect, wjth some patients, of producing sleep for two nights 
after a single administration. Their sedative action ap- 
peared to be most satisfactory, and with few exceptions did 
not produce a drowsy or stupid condition. The dose of 
trionai as a hypnotic is from ten to thirty grains, (grammes 
.66 to 2.) but it is advisable to begin with fifteen grains, 
(gramme 1). As a sedative ten or fifteen grains (gramme 
.66 or 1.) at least are required, but in some patients even 
forty-five grains (grammes 3) will not produce any effect. 
The dose of tetronal as a hypnotic is from five to thirty 
grains (grammes .33 to 2.) but in the majority of patients 
fifteen grains (gramme 1) will be required to procure a 
satisfactory sleep. As a sedative five or ten grains (gramme 
.33 or .66) given once or twice a day will generally prove to 
be of benefit. — American Journal Insanity, April. 



Chloralamide in Nervous Insomnia. — J. S. Leonhardt, 
M. D., says: "Chloralamide seems to more fully overcome 
all hitherto existing difficulties and objections than any 
other medicine I have any knowledge of, and stands to-day, 
or will in the near future, as the calmative par excellence 
in nervous insomnia." He prescribes, 

Chloralamid-Schering 3ijss 

Spts. vini gallici %i] 

Sig. Teaspoonful an hour before retiring. 



332 neurological. [March- J une ? 

A New Substitute for Cocaine is the acetamide of 
eugenol, which is contained in the oil of cloves. It is in 
crystalline form and produces a high degree of local 
anaesthesia. As it has no caustic action and is an energetic 
antiseptic, it may be found superior to cocaine for minor 
operations upon the mucous membranes. (Ihe Lancet, Dec. 

10.) 

Simple Photophobia Treated by the Continuous Cur- 
rent. — An extract of a paper by Dr. Hern on the above 
subject is printed in The Lancet of Feb. 11th. He records 
two cases of photophobia without lesions discoverable by 
naked eye or ophthalmoscopic examination. Patients were 
usually anaemic, of nervous temperament, and in several 
instances were convalescing from a severe illness. Did not 
exhibit hysterical symptoms. He thought simple photo- 
phobia due to retinal change, the exact nature of which was 
undetermined. The treatment he advocated was the 
application of the continuous electric current applied in the 
way described by Dr. Buzzard. Treatment by suggestion had 
been tried, but without effect. Many of the cases occurred 
in rheumatic people. 

B. M. CAPLES. 



Mechanical Treatment of Locomotor Ataxia. — Dr. 
Kubens Hirschberg (Eev. gen. de Therap. med., Jan. 30.) con- 
cludes that the ataxic movements of tabetics may be very 
decidedly ameloriated by the method of Dr. Frankel. Such 
exercises increase the muscular power of the affected mem- 
bers. The exercises, in submitting the muscular contractions 
to the will of the patient, ameliorate the coordination of the 
movements. In raising the morale of the patient and re- 
storing to him his confidence in his legs, pathophobic im- 
perative ideas which so frequently check the motility of 
tabetics are banished. The treatment is indicated in all 
periods of tabes. The best results are obtained when the 
patients have not ceased to walk. The treatment is contra- 
indicated in galloping tabes, especially when the articula- 
tions are affected. The treatment is without effect on 
anything but motion. 



J. G. KIERNAN. 



Treatment of Paralysis Agitans. — Dr. Mendel, of Ber- 
lin, publishes a case in which he produced notable abate- 
ment of the tremor of paralysis agitans by subcutaneous in- 



1893.] THERAPEUTICS. 333 

jections of from 2 to 3 decimilligrammes of duboisine 3 
times a day. In 15 minutes after injection the trembling was 
so moderated as to enable patient to write more legibly. 



Drugs used in Nervous Diseases.— The following is a 
very brief resume of an article by Dr. A. A. Boyer. He first 
mentions remedies for chorea. Arsenic is a tonic, it increases 
number of red blood globules and the general tone of the 
muscular system. In chorea it acts by depressing spinal 
cord action and producing muscular capacity. In acute 
violent chorea, chloral is used to produce sleep. Antipyrine 
is used successfully, but it tends to deteriorate the quality 
of the blood. Concerning remedies for insomnia he thinks 
chloral and sulfonal are much over-rated. — (Jour, Nervous 
and Mental Diseases, Jan. '93.) 



The Treatment of Status Epilepticus. — Kernig in the 
Petersburg Med. Wochenschr., No. 18, speaks of the treatment 
of this condition in which convulsions follow each other so 
rapidly that the patients do not regain consciousness. A 
young woman had convulsions all night and in the morn- 
ing lay in a comatose condition. There was no pulmonary 
oedema and the pulse was good. As the convulsions began 
again she was given a hypodermic injection of 0.02 gm. of 
pilocarpin and at the same time 1.5 gm. of camphor by the 
mouth. This caused a profuse perspiration and the convul- 
sions ceased immediately. For about an hour she was 
threatened with pulmonary oedema and collapse. This 
passed over and was followed by a healthy sleep. An 
elderly gentleman, who had suffered from epileptic seizures 
every four or five weeks, had a severe nervous shock which 
caused the attacks to be more severe and more frequent. 
After convalescing from a light attack of typhus he had 
nine typical epileptic convulsions in seven hours. During 
the intervals he was comatose. Until the fourth convulsion 
his temperature was normal, after the ninth it was 39.2°. 
He was given a hypodermic injection of 0.015 gm. of 
morphia, after which he slept quietly all night. (All- 
gemeine Zeitsch. fur Psychiatrie, Vol. 94, No. 4.) 



JOS. KAHN. 



Maltine with Peptones in Certain Nervous Affections. 
— Dr. Graeme M. Hammond recommends the use of maltine 
with peptones in all nervous troubles where there is any 



334 neurological. [March-June, 

gastro-intestinal irritation. He says that children who are 
doing well on medical treatment and exclusive milk diet 
have improved more rapidly in strength and bodily condi- 
tion when the maltine with peptones was regularly 
administered. Milk was the only diet that heretofore he 
had allowed epileptic children to have, but he thinks they 
do not get sufficient nitrogenous nutrition from this and 
that by the addition of maltine with peptones to the diet a 
sufficient quantity of proteid foodj in a digested condition 
•can be given, with the result of materially benefitting the 
patient's physical condition. He regards it as a most 
valuable remedy for treatment of disorders of digestion and 
for imperfect nutrition. (iV. Y. Medical Journal, Dec. 3, '93.) 



Migraine — An account of a case of intense obstinate 
migraine relieved by copious draughts of water, is recorded 
in The Lancet (Jan. 21, 1893.) Patient had intermittent ex- 
cruciating pain beneath the eyebrow, attacks announcing 
themselves by tension of veins and throbbling of arteries in 
that region. An abnormally thickened lymph produced 
congestion of pituitary membrane, whereby an artery was 
obstructed, whose pulsations rub on neighboring nerve, 
causing throbbling pains. The water served to increase 
fluidity of the lymph, thus accelerate its flow and relieve con- 
gestion. Migraine may be due, (1), to imperfect elimination 
of waste products, often cured by "flushing the drains," (2), 
to pure neurosis or "nerve storm," (3), to errors of refraction, 
(4), to various local conditions of nasal passages and sinuses 
as catarrh, inflammation, necrosis polypi, foreign bodies, 
caries of teeth, (5) to frequent and sudden alterations of lens 
.accommodation. 



The Cure of the Morphine Habit by Sulphate of 
Codeine. — The N. Y. Medical Journal of Jan. 7th contains an 
article as above. Case described was one in which codeine 
was substituted for the morphine, giving it in larger doses. 
After having first reduced the morphine to the minimum, 
codeine was substituted, giving about one grain doses ten to 
twelve times during the 24 hours. This was continued from 
ten to fourteen days. Acetanilide, bromo-caffeine and 
quinine were used as auxiliaries. 



B. M. CAPLES. 



1893.] THERAPEUTICS. 335 

Treatment of Writer's Cramp. — Benedict has relieved 
a case of writer's cramp by injecting carbolic acid in the 
neighborhood of the sensitive point in the course of one of 
the flexor tendons of the related fore-arm. Langdon has 
succeeded in overcoming writer's cramp by having the pen 
held between the second and third fingers in such a way 
that the holder rests upon the latter at an angle of 110 to 
135 degrees while it is supported below by the thumb, the 
index linger resting lightly above. (Med. News, Apr. 15, 
1893.) 

___ B. M. CAPLES. 

Agathin. — Dr. Ilberg reports unfavorably on trials made 
with this substance, which Rosenbaum has praised highly 
as an antineuralgic and anti-rheumatic. Two cases of 
supra-orbital neuralgia, two of sciatica and three of tabes 
reported no relief. One light case of sciatica (first attack) 
reported relief in six days. Four cases of acute and two 
cases of gonorrhoeal rheumatism were not influenced and in 
three cases of chronic rheumatism it was doubtful whether 
the improvement was due to the remedy or to the rest in 
bed. Most of the patients complained of headache, and 
other unpleasant cephalic sensations. Other incidental 
effects noted were; insomnia, vomiting, each twice; diarrhoea, 
pain during urination, subjective sensation of fever, great 
thirst, each once. (Deutsch. Med. Wochensch., No. 5, 1893.) 

G. J. KAUMHEIMER. 



On the Value op the Electrical Treatment of Pressure 
Paralysis. — Delprat believes with Mobius that "it is not 
proven that the action of electricity in organic paralyses is 
at all remedial ; that palsies of central origin are incurable, 
and that those of peripheral origin, as far as they are curable, 
tend to spontaneous recovery and that no facts have been 
advanced to prove that electricity can hasten the "restitutio 
ad integro." To test this opinion he records experiments on 
87 cases of that form of peripheral paralysis, called by the 
Germans "Schlafparalysen," that is, produced by the pressure 
of the body on the members during sleep. Of 87 cases, 33 were 
treated by faradism, 28 by galvanism and 26 were treated in 
such a way that the patients supposed that they were receiv- 
ing electrical treatment, although the circuit was incom- 
plete. Frequent tests by the dynamometer were employed 
and Delprat reaches the conclusions that: 1, the various 



336 neurological. [March-June, 

forms of treatment employed do not differ appreciably in 
therapeutic effect ; 2, that this effect is certainly not greater 
than that of a purely suggestive sham treatment ; 3, that 
the suggestion does not act, as Mobius supposes, in a direct 
manner, as in this case the effect would have been greater 
where the current could be felt. In 33 cases the strength of 
both hands was tested by the dynamometer immediately 
before and after each treatment. In 18 cases which received 
faradic electricity 51 tests were made. The strength of the 
paralyzed arm was greater 18 times ; less 20 times and the 
same 13 times, than before treatment. In 37 cases the 
strength of the sound hand was greater after treatment of 
the other, 18 times; less 16 times; the same as before 3 
times. The same tests with similar result, were applied, 56 
times in 10 cases treated by galvanism, and 11 times in 5 
cases of pseudo-treatment. Indeed the latter showed some- 
what greater absolute gain by the dynamometer readings. — 
(Dr. C. Delprat, Deutsche Med. Wbchenschr., No. 3, 1893.) 

G. J. KAUMHEIMER, 



Case of Myxoedema Treated w t ith Thyroid Extract 
and Thyroid Feeding. — Woman, aged 54, suffered from 
myxoedema for 14 years, was given subcutaneous injections 
of thyroid juice by R. A. Lundie, of Edinburgh. Improve- 
ment rapid for six weeks, then treatment was discontinued 
on account of its causing diffused pains. Abscesses were 
also present, but probably not originating from injections. 
Patient relapsed and the extract was given through the 
mouth. Improvement apparent within a fortnight, and 
general results, five months after beginning of latter treat- 
ment, most satisfactory. Patient is given extract represent- 
ing one-sixth sheep's thyroid twice weekly. It is most 
important to avoid unusual exertion while undergoing 
treatment by thyroid juice. {The Lancet, Jan. 14.) 



Myxcedema Treated by Injections or Thyroid Juice. — 
Mendel (Mm Fall von Myxoedem, Deutsche Med. Wochenschr., 
No. 2, 1893) reports a case of eleven years standing in 
which all the symptoms were well marked. There were 
present mental weakness and apathy, waxy color, and the 
characteristic solid oedema. The only hair on the whole 
body were the few on the head and a very few on the 
genitals. The temperature varied from 34.8° to 36.3° C, 



1893.] THERAPEUTICS. 337 

and she complained greatly of cold. The parotid saliva 
contained mucin. Encouraged by the reports of improve- 
ments through the use of thyroid juice, it was adopted 
in this case. The extract was prepared according to the 
method published by White in the Brit. Med. Jour., Oct. 29, 
1892. The injections were made daily, the dose being at 
first one-half, later three fourths of a syringeful. Neither 
local nor systematic reaction occurred. Mendel reports the 
result as follows : the patient states that she can walk easier 
and feels stronger. She is more loquacious and brighter 
mentally. The swelling, especially of the back and legs, 
has diminished, and the swelling of the right eyelids has 
lessened to such a degree that the eye can be readily seen 
(before only a narrow slit could be seen). The average 
pulse rate has risen from 60 to 70. The quantity of urine 
(previous average 1100 ccm.) has steadily risen, varying 
from 1500 to 2000 ccm. per day, with a rise in the excretion 
of urea from 14.3 gm. per day to between 20 and 25 gm. 
(highest 36.4 gm.) The temperature is over a degree 
higher than before treatment was instituted. In spite of 
this palpable improvement, the diagnosis of myxcedema 
can still be easily made from the appearance of the patient. 
Unfortunately there is nothing in the article to indicate 
how long treatment had been continued at the date of 
report. Dr. Half Wichmann (Ein Fall von Myxoedem, 
gebessert durch Injectianen mit Schilddriisensaft, 1. c.) also 
reports a case of two year's standing, which was fully as 
severe as Mendel's. The patient received in 35 days nine 
injections of one syringeful each of a thyroid extract 
prepared according to Carter's method. At the end of that 
time the improvement had been so great that the diagnosis 
would not have been possible from the remaining symptoms. 
Wichmann does not expect a cure, but thinks he will have 
to repeat the injections from time to time in order to main- 
tain the ground gained. 

G. J. KAUMBEIMER. 



The First Cured Case of Human Rabies. — The case was 
reported by Novie Poppi in Societa med. chir. di Bologna, 
Apr. 15, 1892. The patient was a strong man of 22, who 
had been bitten in the left leg four days before he applied 
to the Pasteur Institute at Bologna for treatment. He was 
given the usual course of treatment and received 48 injec- 
tions within 20 days. He felt well during all this time and 



338 neurological. [March-June, 

was to have been discharged, when he complained of a 
sensation of great heat, violent pain along the spine and 
great restlessness. The temperature was slightly raised, 
the tendon reflexes normal. As the diagnosis of rabies was 
self-evident, the preventive inoculations were resumed and 
eight injections of virulent spinal cord were made. The 
patient became no better ; the weakness increased ; the 
tendon reflexes disappeared and retention of urine and 
constipation set in. The lower extremities were paretic, 
especially the right. He was in that pronounced stage of 
the disease in which, according to Gameleia and Augier, a 
cure is highly improbable. The use of extreme measures 
was therefore justifiable. As Gotti and Protopopoff have 
found that immunity is best conferred on animals by direct 
intravenous injection of the emulsion, and the case seemed 
absolutely hopeless, the attempt seemed justified and the 
intravenous injections were begun on the third day of the 
disease. The injection of 2 cc. of an emulsion of a cord 15 
days old was well tolerated and the injections were continued 
for seven days with material of constantly increasing 
virulence. Under this treatment the condition of the patient 
improved ; the paresis of the limbs, bladder and rectum 
disappeared and the tendon reflexes returned. The tem- 
perature showed an evening exacerbation several times but 
at last became normal. ( Wien. Med. Wochenschr., No. 52, 
1892.) 

G J. KAUMHEIMER. 

Antipyrin. — Dr. A. Kronfeld reports a number of cases of 
epilepsy, chorea and hystero-epilepsy relieved or cured by 
the use of antipyrin in doses of 0.5 to 1 gramme 3 times 
a day. The histories accompanying his article are, 
unfortunately, quite fragmentary in character. — ( Wien. Med. 
Wochenschr., No. 48, 1892.) 

G. J. KAUMHEIMER. 

The Treatment of the Morbid Fears op the Neuras- 
thenic. — Dr. Ewald Hecker relates two cases of morbid fear 
in neurasthenic patients. In both cases the patient was 
•unable to eat in company. Any attempt to do so was 
followed by a violent inspiratory dyspnoea, which did not 
occur when he took his meals alone. A considerable hyper- 
trophy of the inferior tubinated bodies was found in both cases 
occluding both nostrils. Proper treatment of this relieved 
the respiratory spasm. The mechanism of this trouble is 



1893.] THERAPEUTICS. 339 

obvious. The morbid fears of the neurasthenic may also 
have a visceral origin, as pointed out by Ewald in his essay 
on enteroptosis. Becker then points out that the morbid 
fears of the melancholic are logically justified in his own 
mind, while those of the neurasthenic are sudden in origin 
and just as inexplicable to the patient as to those around 
him. From this H. reasons that the melancholic should be 
referred to the closed institution, the asylum, for treatment, 
while the neurasthenic patient should be treated in open 
institutions. He has found general faradization and 
galvanization of the sympathetic (J to 1 M. A. for 1 to 2 
minutes) of value. The diet should bland and varied. He 
warns against the use of cold douches and too energetic 
frictions, but has found local spongings of value. He has 
also learned to fear the use of active cathartics in these 
patients. As the constipation in these cases is due usually to 
spasm of the intestine, opium, belladonna and similar drugs 
are more likely to be of use. The use of morphia and 
alcoholics to cut short the attack is fraught with danger, 
but is occasionally unavoidable. (Berlin. Klin. Wochenschr. 

ISO. 4/, looZ.) G. J. KAUMHEIMER. 

A Case of Myelitis Cured by Suspension. — The case, 
that of a young soldier, began with weakness of the arms 
and legs. When seen some weeks after the first complaint 
the gait was swaying, and the muscular power greatly 
reduced. Romberg symptom was noticed only after a long 
time. Sensation was reduced below the knees. The knee, 
achilles, plantar and gluteal reflexes were absent, the 
cremaster reflex weak, lower abdominal reflex distinct. 
After a few days in bed, upon expectant treatment, all the 
symptoms became much worse. Suspension was then 
instituted, the first seance lasting only 30 seconds. Improve- 
ment soon took place. Within five weeks the Romberg 
symptom disappeared and after the 29th suspension a slight 
but distinct knee jerk was elicited. After the fiftieth 
suspension, the man was dismissed cured. The only 
anomaly remaining was a weakness of the knee jerk on the 
right side, as compared with the left. (Dr. Kirchner, Berlin, 
Klin. Wochenschr, No. 47, 1892.) 

G. J. KAUMHEIMER. 



The Stomach and the Abstinence -Phenomena of 
Morphine. — Hitzig calls attention to the fact that a great 
many of the symptoms complained of by patients who are 



340 neurological. [March- June , 

undergoing the withdrawal of morphine strongly resemble 
those related by the subjects of chronic gastric catarrh. Alt 
has determined that about one-half the injected quantity of 
morphine is excreted by the stomach within the first hour. 
From this Hitzig assumed that the abstinence-phenomena 
spoken of were due to hyperacidity, due to the change in 
the secretory activity of the stomach. He relates experi- 
ments made upon a physician who was taking about 25 cgm. 
per day. The test breakfast was syphoned out, and at the 
beginning of treatment only a bare trace of H CI was found 
in the gastric contents. With the diminution of the dose of 
morphine, the acid gradually increased until on the day he 
got his last dose 1. 35% of HC1 were found. This rose 
later to 1. 90%. The influence of the morphia upon the 
secretion of acid was noticed to last several days. An alka- 
line lavage always followed the expression of the stomach 
contents. The patient stated that he had suffered much less 
this time than in three previous "cures" of the same nature. 
Hitzig then discusses the influence of the therapeutic 
measures adopted (warm baths and trional) and concludes 
that the lavage is the cause of the comparative comfort of 
the patient. Of course the hyperacidity found was only 
relative, not absolute, but was deemed sufficient to explain 
the symptoms. (Berlin. Klin. Wochenschr., No. 49, 1892.) 

G. J. KATTMHEIMER. 



SURGERY AND TRAUMATIC NEUROSES. 



Brain Surgery; Diagnosis; Localization and Operation 
for the Removal of Three Tumors of the Brain, with Com- 
ments upon the Surgical Treament of Brain Tumors. — 
This is the title of a paper by Drs. Charles McBurney and 
M. Allen Starr. The first part, relating to surgery was read 
by Dr. McBurney. It is important, he said, to put all cases 
on record, successful or unsuccessful, until the exact limits 
of surgical treatment of brain tumors and of brain surgery 
generally, had been well established. So far as is known 
eighty-seven operations had been done for brain tumors, 
seventy-four cerebral, thirteen cerebellar. ^Number of cases 
in which no tumor was found, cerebral sixteen, cerebellar, seven. 
Number of cases in which tumor was found and not removed: 
cerebral, one, cerebellar, two. Removal, with recovery of 
patient: cerebral, thirty-eight, cerebellar, two. Removed and 



1893.] SURGERY AND TRAUMATIC NEUROSES. 341 

patient died: cerebral, nineteen, cerebellar, two. Percentage of 
recoveries after successful localization and removal, forty-six. 
Author thought this encouraging. Failures were due to 
lack of sufficient localizing symptoms, inaccessibility of 
tumor or wide infiltration of brain, or to the fact that 
operation had been undertaken only to relieve intra-cranial 
pressure. Thirty-four of the cerebral cases were in motor 
area, and it was when the tumor affected this area that its 
location was easiest to determine. Removal had been 
successful from almost all parts of the convexity; it was 
impossible to reach mesial or basal tumors. Operation for 
cerebellar tumors was essentially exploratory. Tumors had 
been reached in only six of thirteen cases. Assuming that 
accurate diagnosis of brain tumor had been made, and 
localization carefully studied by a neurologist, grave doubt 
would still exist as to the tumor's consistency, vascularity, 
depth in the brain, whether encapsulated or infiltrating the 
brain. Operation should be postponed if there were a moist 
or discharging scalp from eczema. Incision of scalp should 
be free, say three inches in diameter ; horseshoe incision is 
best. A common procedure is to make a trephine opening, 
and then break up the bone by rongeur forceps. Dr. 
McBurney preferred the bone- flap method. Subsequently 
this could be turned down again and would unite, closing the 
wound, or it could be left partly open for a time for removal 
of gauze inserted to prevent hemorrhage. Dura divided, 
presence of tumor might be determined by sight, by palpa- 
tion, blunt probe, or aspirating needle. Wounded vessels 
of pia might be troublesome. Light touch with the cautery 
was the quickest way of disposing of the smallest ones. Useless 
to try to ligate or sew up a bleeding sinus. Pressure with 
gauze or forceps would prove most successful. Haemorrhage 
from cavity previously occupied by tumor controlled by- 
gauze dressing. Dr. Starr then reported three cases : The 
first a farmer ; aged 40 ; good health until this illness, Dec. 
1890, was suddenly seized with a feeling of dizziness and 
distress which turned into a convulsion. Was picked up 
unconscious, remaining so two hours and a half. Right 
side weaker than left. Next six months there was headache 
and occasional nausea. Sight began to get dim, headache 
more intense, becoming localized over forehead and tophead 
on left. Progressive dullness of thought, and difficulty in 
use of language. Optic neuritis worse on left. Knee-jerk 
exaggerated. Right hemiplegia slight. No objective ansesthe- 



342 neurological. [ Mar cli -Jane, 

sia. Diagnosis was of brain tumor, but its situation was 
doubtful, yet he thought that owing to intellectual dullness 
and gradually increasing motor symptoms, and certain inter- 
ference with speech that the second frontal convolution was in- 
volved, with functional implication, by proximity and growth, 
of the motor and insular areas. Patient had had syphilis 
twenty years before ; did not improve under specific treat- 
ment. Analysis of twenty-three cases of tumor of frontal 
lobe had shown mental disturbance in one-half of them. 
The mental dullness in this case pointed to implication of 
this region of the brain. Operation recommended, but not 
accepted. Finally, the patient being much worse, nearly 
blind in the right eye, unable to see letters with the left, 
motor and mental symptoms worse, urine passed invol- 
untarily, an operation was performed by Dr. Starr. Tumor 
found, as expected, in posterior part of second frontal, the 
adjacent portion of first frontal, and upper half of anterior 
central convolutions; larger than had been supposed, measur- 
ing three inches and a half by two inches. It was an encapsul- 
ated sarcoma. Hemorrhage and shock marked. Death took 
place after eight hours. The second case was a fibro-sar- 
coma of the cerebellum and pons. Patient under observa- 
tion about a year. When first seen there was severe frontal 
and occipital headache, vertigo, tinnitus aurium, numbness 
of left side of face and in the mouth, and continuous feeling 
of drowsiness and dullness. These symptoms had developed 
gradually during the preceding three years. During the 
last year vision became double, with increasing blindness ; 
well-marked choked disk, decrease of visual field; speech 
slow and thick; no disturbance of sensation, motion, or 
reflexes; no ataxia. The existence of headache, vertigo, 
tinnitus aurium, nystagmus, diplopia, and choked disc 
established diagnosis of brain tumor; location could not be 
determined. Patient became quite blind. Well-marked 
optic atrophy, deafness in left ear; considerable staggering 
in walking; marked tendency to turn to the right, and to fall to 
right and forward, symptoms which pointed to the cerebel- 
lum as the seat of tumor. Some weakness of right hand. 
That the lesion was on left side was. shown by pain in left 
side of face, tinnitus in left ear, which afterwards advanced 
to deafness, and later, headache remained almost constantly 
in left occipital region. Dr. McBurney made an opening 
about an inch and a half in diameter. Dura protruded 
strongly, indicating pressure within. No tumor could be 



1893.] SURGERY AND TRAUMATIC NEUROSES. 343 

seen or felt. Surface of cerebellum protruded too much to 
be replaced and the excess had to be shaved off. No notice- 
able change in symptoms except that headache was not so 
severe. On. third day patient fell out of bed and blood-clot 
was found beneath the skin-flap. Chill occurred ; tempera- 
ture rose ; stupor increased. Patient died about eleven days 
after operation. Autopsy revealed a glio-sarcoma, not en- 
capsulated, but yet distinct from the cerebellar tissue, situated 
on lower anterior surface of left lobe, extending on lower 
left half of pons. The fifth, auditory and facial nerves were 
pressed upon, but not degenerated. Tumor could not have 
been reached by operation. — The third case occurred in 
a little girl who suffered from headache, gradually advanc- 
ing blindness due to optic neuritis, difficulty of walking, 
marked staggering, but not constantly in any one direction. 
Slight tendency to fall backward and to left. Aching in 
right ear. Diagnosis of cerebellar tumor, probably of 
vermiform lobe, more likely to right than to the left. 
Absence of cranial nerve palsy showed it was not at the 
base. Dr. McBurney operated, chiselling down on the right 
cerebellar lobe, and using rongeur forceps. Nothing found 
except on introducing aspirating needle half an inch from 
the median line, when two drachms of clear serous fluid was 
withdrawn. Nothing was obtained when needle was 
introduced second time. Patient had some shock, but next 
day about as well as before operation. Continued so until 
sudden death in convulsion six days after operation. 
Autopsy showed a glioma two and one-half by two by one 
inch involving the vermiform lobe, and extending to both 
hemispheres, especially right, just under cortex. In its 
center was a small cyst. Dr. Starr has found, according to 
statistics, the percentage of deaths after cerebellar operations 
to be 77, while after cerebral it was 51. {Med. Record, Jan. 

Zl, loyO.) B> M , CAPL.ES. 

Severe Fracture of the Vertex with Replacement of 
a Large Fragment of Bone. — Drs. Page and Hutchinson 
report the case of a man who was struck on the head by a 
piece of coal falling from a height of 120 feet. There was loss 
of speech and of sensibility and motility in the greater part 
of his body, but in other respects the condition of the man 
appeared normal. Swallowed readily and the sphincters 
were unaffected. A segment of the calvarium about 4J by 
2J inches, of a triangular shape, was found depressed com- 



344 neurological. [March-June, 

pletely below the surface of the inner table; its longest 
(posterior) border ran diagonally across the vertex, from 5| 
inches directly above the right, to 4 inches above and J 
inch behind the left auditory meatus, while its obtuse angle 
lay directed forward at a point 4 J inches above the middle 
of the left superciliary ridge. The surface of the depressed 
portion and of the skull for from one-half to one inch around 
was completely stripped of periosteum. Two buttons were 
removed with a half-inch trephine, one in front, about an 
inch from the right extremity of the fracture, the other 
behind and about one-half inch from the left extremity. 
An elevator was introduced and the fragment dislodged. 
Wound was cleansed and the large fragment was re-inserted 
into the gap. Almost immediately upon the elevation of 
the fragment patient lifted his head and inquired where he 
was, and answered questions slowly, but rationally. The 
next morning his temperature was 99 ; pulse 75. The 
patient had occasional nocturnal delirium which rendered 
him difficult to control. A decided irritability of temper 
and suspiciousness of mind on the third and fourth days, 
especially toward his wife, whom he several times ordered 
out of the room. These manifestations, however, soon 
passed away. In ten days the man began to move the left 
leg a little ; in a month could stand alone for a few minutes. 
In six weeks he was able to get into his buggy, or walk about 
slowly with a couple of sticks. A year after the accident 
had perf3ct control over all his muscles excepting those of 
the right leg and thigh, which still feel " heavy and stiff." 
{Med. News, Feb. 18, 1893.) 

B. M. CAPLES. 

An Operation for Re-covering the Denuded Cranium. 
— Dr. Haldor Sneve refers to an operation devised in the 
eighteenth century by an unknown French surgeon in east 
Tennessee. The operation consisted in making multiple 
perforations through the denuded external table of the 
skull down to the diploe, to invite granulation-tissue to 
appear in the openings thus made, in order to fill up the 
denuded spaces, and thereby protect the bare skull and 
prevent exfoliation of the bone, with consequent exposure 
of the brain. The Doctor gives an account of a case upon 
which he operated with gratifying results in the state insane 
hospital at Dayton, Ohio, some years ago. The operation is 
one worthy of more attention than it has received. (Medical 
News, March 4, '93.) 



1893.] SURGERY AND TRAUMATIC NEUROSES. 345 

Removal of Cerebral Tumor. — Booth and Curtis, 
(Annual of Surg.), report case of tumor of left frontal lobe 
successfully removed. Patient aged 24 years, good family 
history; diagnosis based on following main symptoms: (1), 
unilateral anosmia; (2), optic neuritis; (3), aphasia; (4), 
mental change ; (5), external swelling on temple. Tumor 
size of small hen's egg, covered externally and below by 
adherent dura and on all sides by firm fibrous capsule. 
When allowed to go home some three months later, excite- 
ment brought on severe epileptic attacks from which he did 
not recover. Post-mortem revealed all remaining portion of 
left frontal lobe converted into hard tuberculous mass, with 
cavity below it full of soft, cheesy material. Remainder of 
left hemisphere and the right showed no other foci of disease, 
but a softened area of considerable size found in left lobe of 
cerebellum. Paralysis of right external rectus had existed 
but could not be explained as due to lesion found. 



Cerebral Abscess after Otitis Media Acuta Healed 
by Operation. — Truckenbrod (Arch, of Otol, XXI, 21) reports 
a case of this kind occurring in a gentleman aged fifty-four, 
which is the second case of the kind on record. In this case 
the chief diagnostic point was the aphasia, which, according 
to Wernicke, indicates a disturbance in the posterior third of 
the first left temporal convolution of the brain. Hence it 
was assumed that the abscess was situated in the temporal 
lobe. There was also circumscribed pain in that region 
throughout the entire course of the attack. The paresis of 
the right facial nerve, the convulsions in the right arm, and 
the weakness in the right hand, aided the correct diagnosis. 
The agraphia and dyslexia were also all explained by the 
increased pressure in the skull. The mastoid was opened in 
this case, and, although no disease was discovered, there 
were traces of former disturbances. The tegmen was then 
chiseled away, the dura mater and membranes were 
divided, the brain was punctured, and after pus was revealed, 
the brain was pierced with the knife up to the cavity. 
Drainage was accomplished by means of a broad tube. The 
recovery was rapid and excellent, and in six weeks the 
cicatrix had closed. In two weeks after the operation the 
patient wrote long letters with ease. (N. Y. Med. Jour., Jan. 
21, 1893.) 



346 neurological. [March- June, 

A Clinico-Pathological Study of Injuries op the 
Head, with Special Reference to Lesions of the Brain 
Substance, is the title of an article by Charles Phelps, M. D., 
in the K Y. Med. Jour, of Jan. 14, 21, 28. Following some 
general remarks, Dr. Phelps gives an analysis of 124 cases 
which have come under his personal observation and from 
which he deduces his conclusions upon brain injury., He 
divides the cases into three classes, namely: fractures of the base, 
fractures of the vertex; injuries of the encephalon. Nearly 60 
per cent of injuries of the head involve fracture of the base, 
at the same time most of these begin at the vertex. Fractures, 
by themselves, are unimportant, as it is only by their compli- 
cations that life is endangered. These complications are 
haemorrhages, thrombosis, lacerations, contusions and paralyses. 
Their derivatives are meningitis, abscess and atrophy. All 
of these may be produced directly from injury to the 
encephalon without fracture, with the exception of epidural 
haemorrhage, which is the most characteristic complication 
of fracture. Subarachnoid haemorrhage is ordinarily derived 
from laceration of the cortical substance and is often the 
direct cause of death. Subdural haemorrhage most frequently 
depends upon rupture of the arachnoid and escape of blood 
from the pia mater into the arachnoid cavity. Cortical 
haemorrhage, however, is the one most frequently encount- 
ered. Lacerations and contusions are first in frequency and 
importance among injuries to the head as they play a 
part in all fatal cases. In non-fatal cases the process of 
reparation after injury is slow, in others an 
interval of a few moments to several days 
may elapse between date of injury and death. 
There is no tendency to meningeal or visceral inflammation 
with the exception of occasional formation of abscesses. Dr. 
Phelps asserts the important fact in connection with cerebral 
abscess to be that it occurs from direct brain lesion inde- 
pendent of injuries to the scalp, skull or meninges. 
Contusion occurs in three forms : general and limited, affecting 
the brain, and meningeal, involving the membranes. All 
may exist in the same case. In reparation only absorption 
is required and recovery should generally take place. Gen- 
eral contusion is less frequent than laceration. Meningeal 
contusion occasions haemorrhage and inflamation. Trau- 
matic arachnitis, the author concludes, does not result from 
direct injury transmitted through fracture nor from 
inflammatory process, although this complication was form- 



1893.] SURGERY AND TRAUMATIC NEUROSES. 347 

erly thought to be the great danger after injury. Paralysis 
was represented but in a single case, in which there was 
compression • of the optic nerve. Progressive atrophy 
followed and loss of sight was permanent. It is almost safe 
to assume that if a lesion of the brain exists it has been 
produced by a contre-coup at a distance from seat of injury, and 
this point is almost always at the opposite side of the brain. 
Concussion and compression should be abolished as terms 
describing a pathological condition. There is nothing in 
analogy to warrant the assumption that any fatal disorder 
terminates without involving structural change. Symptom- 
atology. Unconsciousness may be regarded as symptomatic 
of brain injury with diffuse effect, but not necessarily of 
diffuse injury. The pulse has no great practical diagnostic 
value, but the temperature is of primary importance. 
Traumatic and alcoholic coma are needlessly confounded, as 
in the latter condition temperature is invariably subnormal. 
In apoplexy, also, the temperature is at first subnormal, 
then normal unless death be imminent, in which case it 
rises. This is in marked contrast to traumatic lesions in 
which elevation is an early and constant symptom. Symp- 
toms peculiar to fracture of the base are serous discharges 
from ears and nose and haemorrhages from the same or 
mouth into the orbital, subconjunctival, or cervical sub- 
cutaneous tissue. The characteristic symptom of fracture 
ot the vertex, aside from a possible serous discharge, lies in 
its perception by sight or touch. Symptoms of encephalic 
injuries are peculiarities of temperature, pulse and respira- 
tion ; unconsciousness ; delirium ; irritability ; paralysis ; 
muscular rigidity ; convulsions ; anaesthesia and hyper- 
esthesia ; pupillary changes ; and, in a late stage, dementia. 
Symptoms of lesser clinical value are cephalalgia, vomiting, 
vertigo, incontinence of urine and faeces. Prognosis. In the 
124 cases cited nearly 40 per cent, recovered. Fractures at 
the base numbered 70, 30 per cent, ending in recovery. Dr. 
Phelps charges laceration with cause of death in 50 per cent. 
of his cases. Treatment. Shaving of the head is most 
important, as it permits discovery of contusions, and 
facilitates the use of the ice-cap, which is of high therapeutic 
value. Trephining should be resorted to in every 
depressed fracture where elevation and thorough explora- 
tion cannot be otherwise accomplished. Absence of general 
symptoms does not relieve the surgeon from responsibility 
of operating. Dr. Phelps concludes his article by saying: 



348 neurological. [March- June, 

" The general principles of operative interference in cranial 
fractures and encephalic injury may be recapitulated and 
formulated as follows : Incision of the scalp, trephination, 
incision of the dura mater, and perforation of the brain, 
severally or together, should have resort without fear or 
hesitation when indicated. Incision of the scalp and 
trephination are devoid of danger and are always justifiable 
for exploration, which in itself constitutes an indication. 
Incision of the dura mater, and incision or perforation of 
the brain are more serious procedures and should be made 
only when positively indicated by the general symptom- 
atology." 

The Treatment of the Wounded Brain. — Adamkiewicz 
reports the results of experiments made to test the effects of 
antiseptics on the brain tissue. The method employed was 
to inject 1 gm. of the fluid used gently into the brain sub- 
stance, in the same direction in all cases. As the effect of 
the puncture is in all cases the same, the varying result 
must be due to the chemical irritation of the injected 
substance. He concludes that, presupposing that the 
human brain has the same irritability as the animal brain : 
1. Carbolic acid, in solutions stronger than 1 to 200, are 
absolutely contra-indicated. In the concentration stated, it 
can be used, though not without causing symptoms of great 
irritation, but without permanent harm. 2. Sublimate 
solutions, even as weak as 1 to 10000 are absolutely contra- 
indicated. 3. Boracic acid in 3% solution is hardly more 
irritant than water, and should always be used for disin- 
fection of brain tissue. (Deutsche Med. Wochenschr., No 2, 

XOoZ. ) Gi J# KAUMHEIMER. 

Two Unusual Cases of Intracranial Inflammation 
following Purulent Otitis Media with Mastoiditis. — 
Deuch (Arch of OtoL, XXL 3) in reporting two cases of the 
above nature, refers to the great danger in such cases of the 
intracranial structures being involved in the inflammatory 
process, from the extension of the inflammation from the 
external surface of the temporal bone. In rare cases the pus 
formed in the middle ear or mastoid appears beneath the 
periosteum, giving rise to the ordinary post-auricular 
abscess. The symptoms are then apt to abate somewhat, 
since the tension is relieved. During this interval, how- 
ever, the pus burrows, dissecting up the periosteum over a 



1893.] SURGERY AND TRAUMATIC NEUROSES. 349 

large area of bone, and thus depriving it greatly of its nutri- 
tion. The next step is a necrosis of this bone over a small area, 
and, as the small sequestrum breaks down, pus is absorbed 
by the dura mater and a meningitis set up. It is not 
necessary even for necrosis to occur in order to set up a 
meningitis, for numerous venous channels exist between 
the external and internal periosteum which can easily carry 
the infection to the interior of the cranial bones. In young 
children before the ossification of the petro-squamous suture, 
infection is especially liable to take place ; for, in many 
instances, this suture encloses a fold of dura mater, which 
increases the chance of infection. The first case reported 
was that of a child, aged ten months, in whom, although the 
mastoid cortex had been perforated at the operation and 
satisfactory communication with the middle ear established, 
yet during the time in which the post-auricular abscess 
remained unopened, the periosteum had been stripped from 
the bone over a large area, which subsequently failed to 
regenerate. In this way perforation at the sutural line took 
place, and, as the external opening over the mastoid 
gradually closed, infection occurred through the sutural 
perforation from the pus within the abscess cavity, leading 
to meningeal inflammation and disintegration. The second 
case occurred in a man, aged forty, and at the autopsy a 
hemorrhagic pachymeningitis was found extending over 
the entire right side, but most marked over the frontal and 
temporo-sphenoidal regions. There was also a small amount 
of pus on the internal surface of the dura. The brain was 
normal. Here the pus from the middle ear, not being able 
to find an exit through the mastoid cells, owing to the 
existing osteo-sclerosis, dissected up the periosteum of the 
external auditory canal and, entering the temporal fossa, 
burrowed beneath the periosteum, denuding the squamous 
and mastoid portions of the temporal bone over a large area, 
and causing a circumscribed necrosis of the squamous 
portion of the temporal bone. Meningitis then followed 
and assumed the hemorrhagic form. — (iV. Y. Med. Jour. 
Jan. 21, 1893. 

Subdural Haemorrhage and Operation. — Dr. F. C. 
Schaefer reports a case where haemorrhage occurred three 
years after injury of the skull. The first symptoms of 
clot were those of localized convulsions, beginning in the 
fingers of the left hand, involving the arm and entire left 



350 neurological. [March-June, 

half of the bod v. Later unconsciousness occurred, follow 

■ hemiplegi hemianaBsthesia and ataxic aphasia with 
mental dullness. The i er the 

arm center, where the sear of the original injury was located. 
He found a subdural hemorrhage and evacuated adout two 
d] of blood. Thr.r were evidences of lepto- 
meningitis Three weeks later the patient was very much 
improved especially the nd meningi: The 

ataxic aphasia was also improved " :ago Clinical I. 
March 

ExiLRPATIOy OF A>" Ls'TKADURAL TUMOB OF THE SPIRAL 

. :: - aged 33. - ned severe shaking 

jumping from a height at age of five,, and at age of seven 
Idenly lost power in legs for four or five months without 
becoming unconscious. This never occurred again. At age 

F2t eg ■; .. . " intervals to suffer from pain localized in line 
extending from third U seventh intercosfl e midway 

- sen parasternal and nipple tinea TL is _ ally 
became worse, later hypersesthe and then of 

right thigh, followed by patches of am n noticed 

some motor disturbance in lower limbs, muscles si 
tendency to spasmodic contraction at eve p. Pain in 

gde of chest es ud spin mid d became 

difficult. Sensibility of lower limbs ::nued to dim: 
bladder and rectum became paralyzed ; paraplegia 
Remained in this condition eleven years. On examination 
m: ades :f thigh atrophied. Pedal reflexes and ankle clonus 
exaggerated Sensi ility abolished over whole body up to 
level of irregular line pas- - \ .-rough fourth dorsal vertebra 
and fifth intern stal spa estine was paralyzed, 

sphincters not. Incision made from seventh cervical to 
below third dorsal vertebra. A roundish mass of whit 
color was seen in subdural space, its upper limit correspond- 
i d g to the upper margin of the arch of third dorsal vertebra, 

~nward to the level of the arch of the sixth dor- 
vertebra. No trace of the cord could be discovered . : .- 
of seat of operation. At a point corresponding to upper 
extremitv of tumor it seemed to be suddenlv flattened out 
and to become merged in the smooth, white, firm surface of 
the dura. Tumor removed. Ez some dimunition 

in exaggeration of refle lower limbs no change in 

patients condition either as regards motor or sensory para- 
lysis. Microscopic examination showed the tumor to be 



1893.] SURGERY AND TRAUMATIC NEUROSES. 351 

fibrosarcoma with here and there traces of myxomatous 
structure. (British Medical Journal, Dec. 31, '92.) 

B. M. CAPLES. 

The Operative Treatment of Trifacial Neuralgia. — 
Dr. Stoker has an article in the Lancet of March 25th in 
which he briefly reviewed the recent work which has been 
done in this direction ; advocated operation on the fifth 
nerve in those extreme cases of epileptiform tic which had 
failed to yield to other treatment and were so severe as to 
destroy comfort or shorten life. He reviewed the various 
methods of neurotomy, stretching, avulsion, neurectomy and 
argued in favor of one or both of the latter as the best plan 
of operative treatment. He decried neurotomy as an 
uncertain and halting treatment, almost sure to be followed 
by return of the neuralgia. He opposed stretching in the 
treatment of purely sensory nerves as a mere temporary 
expedient. The paper dealt especially with cases in which 
he had removed the infra-orbital and gustatory nerves. The 
operation advocated by him in removal of infra-orbital 
nerves, and which he had performed with perfect result, 
was the orbital method of Wagner. In removal of the 
gustatory nerve he had employed the method of Paravacini 
which he advocated as much less formidable than the retro- 
or transmaxillary operations and as giving sufficient access 
in most cases. He concluded that in cases of trifacial 
neuralgia demanding operative treatment, neurotomy is not 
usually a satisfactory or efficient operation. 2. That in 
merely sensory nerves stretching is at best a temporary 
expedient and either should not be undertaken, or, having 
once been performed and followed by return of pain, should 
not be repeated. 3. That the reasonable treatment in 
trifacial neuralgia of an extreme character is neurectomy 
and that whilst the operation on divisions of the fifth nerve 
external to cranial cavity may be regarded as an established 
procedure, the ultimate operation of removing the Gasserian 
ganglion must still be regarded as on its trial. 4. That 
avulsion should only be practiced as a part of the open 
operation and should only be undertaken when open 
operations are, for sufficient reasons, impossible or inex- 
pedient. The author did not think the situation of pain a 
definite indication of the portion of nerve engaged nor that 
there was any danger in removing the nerve behind the 
sphenopalatine ganglion. B . M . C aples. 



352 neurological. [March-June, 

Removal of the Gasserian Ganglion. — The Med. Record 
notes an intra-cranical operation by Prof. D'Antona in 
which resection of second and third divisions of trigeminal 
nerve and extirpation of corresponding part of Gasserian 
ganglion was performed. Patient, a woman, suffering from 
tic douloureux with convulsive movements of hand and 
tongue. The convulsive seizures, which had numbered one 
hundred a day, ceased immediately after operation, and on 
the eleventh day patient was making rapid progress toward 
complete cure. 

Destruction of the Gasserian Ganglion for Trige- 
minal Neuralgia. — Dr. Roswell Park reports two cases. The 
first, a man aged 53, thin, haggard, showed evidence of intense 
and prolonged suffering. History is one of chronic, intract- 
able, spasmodic facial neuralgia of right side of five years 
standing. The pain first involved second division of fifth 
nerve, later it involved ophthalmic division, and rarely, pain 
shooting down third division. Operated, proceeding as fol- 
lows: exposed the zygoma by an "H" shaped incission, 
sawed it in two places, turned down detached portion with 
the masseter muscle. To secure the zygoma in place again 
necessary to drill each side of each line of section, drill holes 
being made before dividing bone. Turning down zygoma 
exposes the coronoid process of inferior maxilla with inser- 
tion of temporal muscle. This process also drilled tw 7 iceand 
and sawed across. With mouth widely opened there is a 
space sufficient to allow one to attack base of skull under 
Gasserian ganglion ; internal maxillary artery will probably 
require ligation. Then pterygoid plate is reached from 
which external pterygoid muscle takes its origin. This 
muscle is cleared away by detaching it from bone, perhaps by 
dividing it. Although a useful muscle it is not essential and 
may be entirely removed. Following external pterygoid plate 
as a guide foramen ovale is reached. The Gasserian ganglion 
lies between two layers of the dura mater, which splits to 
enfold it. It is not possible to exsect the ganglion as one may 
remove a tumor, as it is concealed from view and is soft and 
friable. Haemorrhage is considerable from the numerous small 
vessels in the spheno-maxillary fossa. This difficulty the 
author has decided to obviate by tying common carotid 
artery at point of election. He then makes an "H" shaped 
incision from the zygoma, makes the four drill holes and 
saws and chisels through the bone. The trephine is used 



1893.] SURGERY AND TRAUMATIC NEUROSES. 353 

to expose the ganglion and small chisels for the rest. The 
dura then opened, the ganglion broken up with a blunt 
hook, second branch pulled out from foramen rotundum 
and together with Meckel's ganglion excised. Small inci- 
sion made over the supra-orbital notch ; nerve found and 
pulled out from its channel until it broke ; external portion 
was removed. Pain was relieved at once and patient 
returned to his home in about twelve Tlays. — (Medical News, 
Feb. 18, 1893.) 

Radial Nerve Suture. — Dr. Guelliot (Gaz. des Hop. 
Feb. 9, 1893) reports the case of a workman whose arm had 
been torn by a machine and radial nerve section had 
resulted; immediate suture was declined. Two months later, 
when the wound was almost cicatrized, the patient demanded 
operation as radial paralysis persisted. The severed ends of 
the nerve was drawn together and sutured by double catgut 
and decalcified bone. Sensibility, abolished on the forearm, 
returned pretty rapidly until there was but slight zone of 
anaesthesia. The paralysis was not improved and atrophy 
continued. 

J. G. KIERNAN. 

The Laryngoscope in the Diagnosis of Traumatic 
Neurosis. — Holz has stated that in some cases the 
laryngoscope might furnish objective symptoms of trauma- 
tic neurosis in the shape of paralysis of the laryngeal 
muscles. Dr. H. Burger has reviewed Holz's article and 
concludes : 1. Functional paralyses of the adductors of the 
vocal cords are, a priori, not improbable in traumatic 
neurosis, although they have not been frequently observed. 
2. They are of no value in the differential diagnosis 
between traumatic neurosis and simulation. 3. Paralysis 
of the dilators of the glottis and of the recurrent nerve, as 
a symptom of traumatic neurosis, has not yet been described 
and are hardly likely to occur. (Berlin. Klin. Wochenschr., 
No. 47, 1892.) 



G. J. KAUMHEIMER. 



ACCELLERATION OF PULSE IN TRAUMATIC NEUROSIS. — 

Arthur Strauss (Berlin. Klin. Wochenschr., No. 48, 1892) reports 
the results of investigations made to determine the value of 
Mannkopff's phenomenon (accelleration of the pulse on 
pressure upon painful points) in traumatic neurosis. He 



354 neurological. [March-June, 

made observations upon a large number of patients and 
reaches the conclusion that it is of confirmatory value only. 
That is, its absence does not indicate that the patient is a 
simulator. 

G. J. KAUMHEIMER. 

Syphilis and the Nervous System. — Dr. H. N. Moyer, in 
a paper read before the Chicago Academy of Medicine, says : 
Though medicine is still in the dark regarding the exact 
pathology of syphilis, it is generally accepted at the present 
time that it is due to the development of a special bacillus, 
though that has not yet been determined. There is a close 
analogy between the exanthematous disorders and those 
that have a demonstrable bacillus. In the main, syphilis 
pursues a very similar course. There is the period of inva- 
sion, the febrile stage, the eruption, and finally desquama- 
tion. It is more than probable that these mark but stages 
in the development of the life-history of this organism in 
the body. Like the exanthemata, syphilis is very prone to 
affect the nervous system. It attacks with greatest frequency 
the spinal cord, and next, the brain. The portions which 
are the least often affected are the peripheral nerves. 
Syphilis rarely attacks the nervous system at its onset. 
Cases occur of precocious involvement of the nervous 
system, but are decidedly exceptional. He has seen a case 
in which all symptoms of posterior spinal sclerosis were 
present, including the Argyll-Robertson pupil, lightning 
pains in the feet and inco-ordination, associated with a 
diffuse papular and macular syphilitic eruption in the 
secondary stage of the disease, and not more than three 
months from the possible primary infection. Of course, the 
question might be raised as to whether this was not an 
accidental infection of syphilis in locomotor ataxia — that is, 
whether the disease did not exist prior to the infection — 
but careful examination seemed to exclude this, and 
showed that the ataxic symptoms developed co-incidentally 
and after the primary infection. Of late years there has 
been abundant evidence that syphilis stands in etiological 
relation to several important diseases of the nervous system, 
as, for instance, paretic dementia, locomotor ataxia, ataxic 
paraplegia, and lateral sclerosis. Too much importance has 
been, however, attached to the fact that the history of these 
patients shows that they have been infected with syphilis. 
Mere coincident phenomena do not necessarily prove that 



1893.] SURGERY AND TRAUMATIC NEUROSES. 355 

they stand in the relation of cause and effect : but where as 
many as 80 or 90 per cent, of crises have syphilitic infection, 
it is fair to suppose that syphilis stands in causal relation to 
the disorder. Early involvement of the nervous system in 
syphilis is quite a different thing from later involvement. 
The earlier cases are presumably due to the direct effect of 
the bacillus, or to the generation of ptomaines or toxines, 
during its development in the body. The pathology of 
these lesions is quite different from that of the later ones, 
and they yield readily to the remedies appropriate for 
syphilis. The changes which come on from three to 
twenty years after infection are not probably due directly 
to the syphilitic infection, but rather to the nutritional 
disturbances to which the syphilitic infection has given rise; 
in other words, the syphilis has acted as a predisposing 
cause, just as heredity or other predisposing factors may act. 
The lesions themselves have ceased to be syphilitic, although 
the infection has furnished a foundation upon which they 
ha\e been built up ; therefore in these cases anti-syphilitic 
treatment is for the most part ineffective. Too much 
importance has been attached to syphilitic infection in the 
development of certain nerve disorders to the exclusion of 
other factors quite as potent. In the development of loco- 
motor ataxia it is not infrequent to have sexual excess 
associated with previous syphilitic infection. In paretic 
dementia, syphilitic infection is often accompanied by abuse 
of alcohol and extremely irregular modes of life. In these 
cases the factors determining the nature of the disease are 
several ; it is a resultant of several causes, and not one 
cause, and it is extremely important that physicians should 
carefully warn all patients who have once been infected 
with syphilis to avoid all causes of excess, to lead regular 
lives, to avoid worrv and excitement, to avoid alcohol in 
any form, if they would remain free from later and very 
serious involvement of the nervous svstem. (Chicago Medical 
Standard, May, 1893.) 

Sinus Thrombosis, Attended with Remarkable Ocular 
Symptoms. — Shield {Arch, of OtoL, XXI, 3) reports the case 
of a man, aged thirty-five, who had long suffered from right 
otorrhcea. The right eye was more prominent than the left. 
There was complete right ptosis, followed three days later 
by left ptosis, and there was occasionally slight delirium. 
The patient had a dry, cracked tongue, and lay in a 



356 neurological. [March- June r 

drowsy state. The exophthalmos was so marked as to 
suggest the presence of tumors in the orbit. The lids were 
greatly swollen and the left iris was dilated and immovable. 
Well-marked optic neuritis was present in both eyes. A 
thrombosed vein existed at the root of the nose. The dis- 
charge from the right ear was profuse, the drumhead w r as 
destroyed, and the drum cavity filled with granulations. 
There was no oedema or tenderness over the mastoid, but 
there was distinct fullness and local tenderness over the 
upper part of the jugular vein. The thrombosed vein at 
the root of the nose suppurated just before the patient's 
death. The exophthalmia undoubtedly depended on venous 
engorgement, due to blocking of the cavernous sinuses by 
clots, which extended by way of the petrosal and transverse 
sinuses from the right lateral sinus. The angular and 
frontal veins were also thrombosed. The evident implica- 
tion of the third nerve on the left side w r as due to pressure" 
in the cavernous sinus. The right facial paralysis was due 
to direct implication of the trunk of the seventh nerve in 
the aqueduct of Fallopius. The origin of the mischief was 
caries of the right mastoid and thrombosis of the lateral 
sinus. There were three small abscesses in the cerebral 
cortex, and a fourth in the right corpus striatum, embolic 
in origin. The ophthalmic veins w r ere full of firm thrombi. 
The cavernous and petrosal sinuses were full of pus. (N. Yi 
Med. Journal, Jan. 24, 1893.) 



Eclampsia, according to Dr. Pinard (Mecredi Med., Feb. 1,. 
1893) is a manifestation of gravidic auto-intoxication result- 
ing from retention or from insufficiency of the organs to 
eliminate or destroy poison. Tarnier had shown that milk 
diet was an excellent prophylactic. Dr. Pinard had, between 
1889 and 1893, under observation at the Baudelocque clinic 
about 5000 gravid women, sixty-one of these were decidedly 
albuminuric and were confined to milk diet. In not a 
single case did eclampsia result. In France induction of 
labor was regarded as at best useless. Dr. Pinard had found 
nothing superior to chloroform or chloral as a calmative of 
hyperexcitability. In ten years he bad treated 79 women 
at the onset of eclampsia. Of these thirteen had died and 
66 recovered. Some had not died from coma but from 
consecutive haemorrhagic or septicaemic complications. In all 
cases antiseptic precautions were necessary. Dr. Gueniot 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 357 

agreed with Dr. Pinard that eclampsia was due to auto- 
intoxication, but hyperexcitablity of the spinal cord often 
played a prominent role. Delivery alone often sufficed to 
check the convulsive phenomena. In such cases the 
toxaemia could not be said to be remedied although the 
cause of spinal hyperexcitability was removed. Frequently, 
when albumen was absent from the urine, violent 
cephalalgia, vomiting, blindness, etc., were precursors of the 
eclamptic onset. Dr. Lanceraux was of opinion that a 
renal lesion diminishing the excretion of toxic principles 
was a primordial cause to be taken into account in dealing 
with etiological factors. Spinal hyperexcitability put in 
play and increased by labor was a secondary phenomenon. 
Milk diet and chloroform were of use but Dr. Lanceraux 
had found drastic cathartics of value at the onset. Dr. A. 
Robin was of opinion that spinal hyperexcitability was a factor 
to be little considered in view of the undeniable existence of 
toxaemia. Local bleeding in the renal vicinity had a 
physiological basis in view of the considerable communica- 
tion between the subcutaneous and renal capsule veins. He 
was of opinion that agents like benzoic and salicylic acid 
exerted a beneficial chemical action on the toxic products in 
the circulation. Dr. Tarnier had had useful results from milk 
diet. He had seen albuminuric blindness in a pregnant 
woman disappear under it. Spinal excitability was merely 
a symptom. 

J. G. KIERNAK. 



PSYCHOLOGICAL. 



PATHOLOGY AND SYMPTOMATOLOGY. 

Isotonia of the Blood in the Insane — Agostini pub- 
lishes, (Riv. Sperimenlale XVII T, III and IV, 1892) the results 
of his examinations of the blood of the insane in the asylum 
of Perugia. He studied especially the power of resistance of 
the red globules to the solvent action of distilled water as 
measured by the quantity of salt required to prevent this 
solution. This resistance has been named by Hamburger 
isotonia and the adjective isotonic applied to the saline 
solution that prevents the exit of the haemoglobin from the 
corpuscle. The weaker this solution required, the greater 
is the resistance. In this investigation he used Mosso's 



358 psychological. [March-June, 

method, somewhat modified, in preference to those of Ham- 
burger and Limbeck, and his results are summed up as 
follows : (1.) That the average physiological resistance in 
the sane varies in males, between gr. 0.44 and gr. 0.46 and 
in females between gr. 0.46 and gr. 0.48 of chloride of 
sodium to the hundred grammes of water. (2.) That the 
isotonic power of the blood in the insane is found in a 
majority of cases to be below the normal. (3.) That the 
maximum hypo-isotonia is met with in pellagra. (4.) That 
after pellagrous insanity, a considerable diminution in 
globular insistence is met with in depressed melancholic 
conditions, especially if accompanied with agitation ; in 
idiocy, neurasthenia, in post-epileptic conditions, in post- 
hemiplegic dementia, and in paralysis of alcoholic or 
syphilitic origin. (5.) That a resistance below the normal, 
but less marked, is met with in maniacs, in states of 
maniacal excitement, in paralytic insanity, especially in its 
advanced stages. (6.) That it reaches the normal average 
in imbeciles, epileptics, hysterical cases, paranoiacs, and 
tranquil and senile dements. ^"0 That the isotonic 
power is re-established slowly in cases where it has 
been lessened and in curable cases a return in the 
normal is a suggestion of a favorable prognosis. 
The quantity of haemaglobin was tested with Fleischl's 
haemometer and found to be least in pellagra, and nearly 
normal in epilepsy. paranoia, paralysis, imbecility, 
hysteria, and dementia. In idiocy hypoglobulia was rather 
common. Pellagra was also the form in which the specific 
weight of the blood was most frequently below the normal 
and the other forms of insanity held about the same relative 
positions to each other, as was the case with hypoglobulia. 
In the majority of the maniacal types the isotonic power was 
somewhat reduced, the proportion of haemoglobin was below 
the normal, while the number of globules remained nearty 
normal. In the depressive types of insanity, in idiocy, in 
post-hemiplegic dementia, the isotonia is still lower, the 
quantity of haemoglobin diminished with greater frequency 
and the percentage of hypoglobulia notably increased. The 
globular resistance is still further weakened in the toxic 
forms, also the richness in haemoglobin, and the number of 
globules decreased. Pellagra takes the lead in all these 
respects. In the period of agitation, especially if prolonged, 
of epileptics, hysterical cases, paranoiacs and dements and 
after epileptiform and apoplectiform attacks, the isotonic 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 359 

power is lowered, but without much modification of the 
quantity of haemoglobin or the number of globules. In 
typical paresis the isotonic power is little inferior to the 
normal, and in most cases the haemoglobin and number 
of globules are physiological, while in the periods of 
prolonged agitation that sometimes end in marasmus, 
all these are notably lowered. In imbeciles, epileptics, 
hysterical cases, paranoiacs and dements, the isotonic 
power and the richness in globules and haemoglobin 
all oscillate near or about the physiological mean, in the 
majority of cases. The exact relation between the altera- 
tion of the blood and the insanity is not clear, but the 
author calls attention to the facts of the influence of the 
nerve centres on anaemia and vice versa as suggestive in this 
connection as, together with other facts, indicating a 
probable direct mutual connection between the nervous 
system and the sanguine crasis. 

H. M. BANNISTER. 



Hematoma Auris. — Pellizzi (Riv. Speriment, XVIII, Hand 
III) sums up the conclusions of a paper giving the results 
of a clinical and bacteriological investigation of haematoma,as 
follows: (1.) The clinical and anatomical facts and the 
bacteriological and experimental observations lead me to 
admit an infective origin of the othaematoma of the insane. 
In five cases I have been able to study there has been found 
a chain coccus of four to ten elements, very similar to the 
streptococcus of erysipelas and to the streptococcus pyogenus. 
(2.) It is of little importance to determine in which form of 
mental disorder haematoma is most likely to develop, and it 
is of no certain value as regards the prognosis of the insanity. 
(3.) The opening of the cavity of the othaematoma and its 
washing out freely with an antiseptic solution is a very 
rational and necessary method of treatment. (4.) The 
opening should be done in the first begining of the tumor; 
the washing should be repeated, abundant in quantity, and 
injected rather forcibly against the walls of the cavity. (5.) 
It is necessary when othaematoma appears in a ward full of 
patients, to employ full antiseptic precautions, especially 
after it has been opened and freed of its contents, so as not 
to convey to other patients the germs of the disorder. 



H. M, BANNISTER. 



360 psychological. [March-June, 

Menstruation in the Insane. — The V/ien. Med. Presse, (No. 
52, 1892) brings the following abstract of an article by H. 
Bissell in Centralbl. f. Gyn. No. 43 : Almost all the patients 
showed greater irritability at the menstrual period, and 
often increased tendency toward violence. Even convulsions 
can occur. The convulsive tendency is especially marked 
at this time in epileptics, even with normal genital organs. 
Per contra the removal of lesions of the genitalia has usually 
little or no influence upon the epilepsy. The convalescent 
patients complained occasionally of dysmenorrhoeic 
symptoms. The severe cases were indifferent to such pains. 
Intermenstrual intervals of 3 to 5 weeks must be considered 
normal. In the chronic insane, the menopause has no 
influence upon the psychosis. In acute psychoses the 
menstruation usually returns with the improvement in 
general health. It is of bad prognostic significance if the 
mental improvement does not keep pace with the physical 
improvement. The menstrual irregularities and the mental 
disturbances are much oftener the results of the same cause 
than they are in the relation of cause and effect. General 
remedial measures are to be preferred to local treatment. 

G. J. KAUMHEIMER. 



Paretic Dementia and Syphilis. — Dr. J. G. Kiernan says 
that the tendency of recent medical opinion is toward the 
view that P. D. has a syphilitic aetiology. He furnishes 
histories of interesting cases that have been under his 
observation. (Alienist and Neurologist, Jan., '93.) 



General Paralysis at Puberty. — While general para- 
lysis is confined mainly to adult life it is by no means 
exclusively so. Dr. J. Wiglesworth (British Med. Journal, 
March) records two cases occurring in girls at 12 and 14 
years, proving fatal at 16 and 18 years, respectively. Both 
previously intelligent, both said to have started from a fall, 
this, however, may have been simply an early symptom. 
Mental symptoms, those of slowly progressive dementia, 
without grandiose ideas ; soon gradual failure of mental 
power, followed by slow progressive paresis of limbs, until 
absolutely paralyzed and contractures developed ; epilepti- 
form convulsions noted in each. Necropsy showed thicken- 
ing and opacity of arachnoid with adhesion of pia mater to 
cortex, in one case decortication ; enormous wasting of con- 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 361 

volutions, great atrophy of cortex, whilst in one was an old, 
thick, organized subdural membrane. Analysis of these 
cases and six other published showed average age disease 
commenced at 14 years, average duration 4J years ; five of 
the eight were girls, reverse proportion to that shown in 
adult paralysis ; mental symptoms showed preponderance 
• of demented type of general paralysis ; signs of puberty did 
not appear at all or were arrested and tended to disappear, 
menstruation in females absent; and arrest of bodily 
development. The most prominent probable factors in 
production of the disease were heredity and congenital 
syphilis, traumatism being, perhaps, an additional cause in 
some cases. 



Tabes and Paretic Dementia. — Dr. Courtois-Suffit passes 
in review (Gaz. des Hop., Jan. 14, 1893) the various views 
anent the relationship of tabes and paretic dementia. He 
cites Raymond as stating (Gaz. des Hop., April 8, 1892) that 
"clinical facts demonstrate that tabes and paretic dementia 
are two disorders frequently associated together. The 
morbid accidents often make their onset in tabetic form 
while paretic dementia closes the scene. Both have a 
common aetiology dominated by lues and heredity. In 
both the central lesions involve the same organic systems, 
so that it seems justifiable to ask whether the two disorders 
be not the same disease." This declaration of Raymond 
opened an active discussion before the Paris Hospital Society 
in which Ballet and Joffroy sustained the dualist view, 
claiming that coincident existence of two diverse disorders 
would explain all the facts cited by Raymond in favor of 
unity. Rendu sustained Raymond's claim for unity. 
Courtois-Suffit in discussing the question analyzes the various 
views as to the mental state of tabetics. He points out that 
at the period when tabes and dissimilar neuroses were con- 
founded, good humor and resignation were said to be 
characteristic of tabetics. Later Duchenne (de Boulogne) 
and Trousseau in demarcating tabes took especial care to 
maintain the permanently perfect mental intelligence of tabet- 
ics. These views, as Dr. Courtois-Suffit remarks, must appear 
strange to clinicians who have given prolonged care to 
tabetics. Grisolle later went even further and stated that 
tabes and paretic dementia were absolutely dissimilar. 
However, observations were not wanting to contradict this- 



362 psychological. [March-June, 

view. Towards 1830 Horn, Hoffman and Tiirck cited cases 
of tabes conjoined with paretic dementia. Following them 
Baillarger, Foville, Topinard, Jaccoud, Luys, Magnan, 
Westphal, Spitzka (Jour, of New. and Merit Diseases, 1877 , 
Kiernan (Jour, of Nero, and Ment. Dis., 1878) and others 
insisted on the close relationship of the two neuroses. 
Foville claimed that this morbid association was due to the 
ascension from the cord to the brain. Magnan insisted that 
the tabetic symptoms often preceded the paretic dementia 
by years. Raymond (Diet Encyclopedique, 1885) insisted 
eight years ago on the clinical significance of these facts. 
That syphilis dominates the aetiology of most cases of paretic 
dementia and tabes is pretty generally admitted. Fournier 
has examined 400 tabetics as to lues with the following 
results : First hundred had 89 syphilitics ; second hundred 
93 ; third hundred 91 ; fourth hundred 92, w T hich gave an 
average of 91 syphilitics of the 100. The influence of lues 
on paretic dementia is not so readily settled as the difficulties 
of statistic collection are greater. There are decidedly 
contradictory opinions expressed. Lasegue in 1861 stated 
that there were both a true paretic dementia and 
mimicking paretoid states. There was no luetic paretic 
dementia but a luetic paretoid state. Diagnosis between 
them was impossible. Treatment could not settle it. 
Esmarch and Jensen in 1887 expressed the opinion that 
paretic dementia was always luetic. Griesenger (Mental 
Diseases) denied luetic aetiology while Kjellberg claimed 
that all paretic dementia was of luetic origin. Coffin 
claimed that precocious paretic dementia (evolving between 
25 and 28) was most frequently, if not always of luetic 
origin. Fournier in 1879 discussed very lucidly the luetic 
aetiological question, deciding it affirmatively. He placed 
paretic dements in two categories. Those of classic type 
with regular symptoms and patho-anatomy and those in 
which the symptoms of paretic dementia were associated 
with symptoms foreign to this disorder. In cases of the 
second group, he claimed, there could be noted a mental 
state absolutely free from the ambitious delusions of true 
paretic dementia. Trembling of the tongue and much 
more of the upper lip was rare in pseudo-paretic dementia 
of luetic origin. There was a difference in the onset of the 
two types. The pseudo-paretic had a cachexia. The true 
paretic was florid. Curability was an excellent criterion. 
Meningeal sclerosis predominated in the luetic type ; 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 363 

encephalitic sclerosis in the true type. This view was 
adopted by Malet, Ball, Mickle and Schultze. At the same 
time the opposite opinion that no pathognomonic demarca- 
tion between the two types was possible gained many 
supporters. Foville insisted that differential criteria of 
luetic pseudo-paretic dementia proposed by Fournier were 
valueless. This view was also previously expressed by 
Lancereaux, Miiller, Huguenin and A. Voisin. Kiernan in 
1883 advanced the same view (Alienist and Neurologist, 1883). 
Since 1880 Christian and Magnan have denied that lues 
could produce paretic dementia. Regis, on the contrary, 
claimed that lues was a constant factor in 70 to 75 per cent 
of his paretic dements or if probable, not certain, luetic 
infection, was taken into consideration, the percentage rose 
to 94. In 1889 Morel-Laville showed that certain luetics 
became paretic dements more readily than others, whence he 
concluded that lues had at times a more positive neurotic 
tendency and that the character of both the predisposing 
and exciting cause must be taken into consideration. This 
opinion was essentially that of Raynaud. Reynier (Rev. de 
Med., 1889) claimed that lues and paretic dementia could 
co-exist in the same subject and pursue an independent 
course. The patho-anatomical lesions remain distinct as to 
seat and evolution. The occurrence of syphilis in paretic 
dements as found by observers varies greatly. Furstner 
has found 33 per cent. ; Goldsmith announces the 
same ; Ziehen has found 43 per cent, in the male, 
and 46 per cent, in the female; Binswanger 49 per 
cent.; Mendel 74.6 per cent.; McDowall 80 per cent.; 
Jespersen 82 per cent. Kjellberg claims that paretic 
dementia occurs only in organisms that are the victim of 
syphilis inherited or acquired. It is interesting to note in 
connection with this last dogmatic opinion how often lues 
has been demonstrated in early paretic dementia. Raymond 
cites (Neurol. Centralbl., 1888) the case of a thirteen year old 
girl whose father had been infected two years before her 
birth. She remained in seeming mental and moral health 
until her thirteenth year, when, with the precursory 
phenomena of menstruation, the symptoms of paretic 
dementia and tabes coincidently appeared. After similar 
careful analysis of tabes Dr. Courtois-Suffit comes to the 
conclusion that tabes and paretic dementia are both post- 
syphilitic in the majority of cases and that a local inherited 
predisposition influences the selection of the brain or cord. 



364 psychological. [March-June, 

Such a predisposition may lead to the simultaneous 
appearance of two distinct disorders like paretic dementia 
and tabes. 

J. G. KIERNAN. 

Alcoholic Paretic Dementia. — According to Dr. Henry 
Berbez, ("Rev. Intemat. de Biblio. Med." Jan. 25) chronic 
alcoholism may, in a certain number of cases, terminate in 
paretic dementia. Such paretic dementias have nothing 
special in their symptomatology, but coincident with paretic 
dementia symptoms alcoholic psychic and neurotic symptoms 
may persist. In alcoholic paretic dementia, arterial 
atheroma, evident in sphygmographic traces, may be present. 
Paretic dementia must be distinguished from chronic 
alcoholism. This is difficult in intermediate stages where 
alcoholics are becoming paretic dements. It must also be 
distinguished from insanity of hereditary origin set in action 
by alcoholic action. 

J, G. KIERNAN. 

Variation in Type of Paretic Dementia. — Dr. St. John 
Bullen concludes from his own experience, supported by that 
of other specialists, that paretic dementia is undergoing a 
change of type. His conclusions are : 1. Less pure and 
sthenic type of mania, with more infrequency of occurence. 
2. Greater frequency of primary demented cases, and an 
earlier onset of dementia in cases where emotional mani- 
festations are primary. 3. Possible increased ratio of 
melancholic to maniacal symptoms. 4. Modification in ages 
of patients attacked, in the duration of the disorder, and in 
its distribution as to sex. 5. Variation in the relative 
frequency in occurrence of convulsive and apoplectiform 
seizures; in a less sthenic character of the former, and in 
diminished frequency and fatal significance of them. 6. 
A possible concurrent change in the meningo-encephalic 
adhesions (post-mortem). (Journal Mental Science, Apr. 93.) 



Periodic Paranoia. — Kausch reviews the literature of 
the subject and reports a case of his own, from* which he 
draws the following conclusions: (1.) Periodic paranoia, 
like other periodic psychoses, is found almost exclusively in 
persons of neurotic inheritance. (2.) The hallucinations 
and delusions do not obtain such complete mastery over the 
patient as in the ordinary forms of paranoia. (3.) The 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 365 

recurring attacks present an unusual similarity in their 
symptoms. (4.) Unlike periodic mania and melancholia 
the patients are entirely or almost entirely sane during the 
intervals. (5.) The prognosis is unfavorable as regards 
a cure, but dementia develops less frequently than in periodic 
mania or melancholia. (Archivfur Psychiatrie, Vol. 14, No. 3.) 

JOS. KAHN. 

Paranoia Politkja. — KrafFt-Ebing has added a chapter, 
bearing this title, to the last (third) edition of his work on 
Forensic Psychopathology. Owing to its great interest, its 
main points are here reproduced from Wien. Med. Blatt. 
No. 48, 49, 1892. In history as well as at the present time 
we meet with a great number of personages, who, dissatis- 
fied with the social conditions surrounding them, feel 
themselves called upon to reform the world, or at least to 
supplant the old with something new. The main difference 
between the real genius and the pseudo-genius is that the 
genius has not only the mental organization to see the 
defects of his surroundings but also the mental force to 
expand his ideas for its betterment in a logical and useful 
way. The pseudo-genius, whose mental developement is 
one sided, resembles the genius in the originality of his 
views and his power of induction. In the expansion of 
these ideas, however, he becomes irrational and eccentric. 
The clinical manifestations of this disease presents an 
infinite variety. In many the intellectual force is slight 
and their mental product of such a nature as to bear the 
stamp of crankiness and not of genius. If aesthetic and 
ethical defects coexist, their ideas are often a priori mon- 
strous or immoral. In many cases however, the mental 
developement is brilliant though onesided, and then the 
danger is imminent that the thoughtless crowd accepts the 
single brilliant thought as a new gospel. Very many of 
these abnormal subjects remain throughout life theoretical 
reformers and leaders of new movements, but this is but the 
prodrome of a severe and incurable mental state, paranoia 
expansiva. Such individuals easily lose the remnant of 
their mental stability under the suggestive influence of 
others or of troublous times. Then they are impelled to 
carry their ideas into execution and become leaders of riots 
or founders of new parties or sects. The stage of incubation 
is long, often reaching back to early youth. A dreamy 
fantastic behavior, a tendency to build air-castles of future 



366 psychological. [March-June,, 

greatness, great self consciousness with seclusion from the 
vulgar herd, premonition of a great mission in life and brood- 
ing over inventions or social problems, are related in the 
early history of these cases. Frequently neuroses, (epilepsy, 
hysteria) are to be noted. Paralogism, disturbances of 
memory, sudden occurrence of primordial delirium (inspira- 
tions) are as common to this form of paranoia as to its other 
forms. It is noteworthy that these pseudo-geniuses, in times 
of a popular excitement easily carry away the masses. 
Lombroso has pointed out how many social rebels, com- 
munards and other reformers have been physically 
degenerate and that a considerable percentage was insane at 
the time of their appearance on the scene, or became so 
afterward. At last such subjects develope complete 
delusion of grandeur and if by any chance they ever attain 
to power, they become tyrants by virtue of their degenerative 
tendencies. If, before this, they are isolated in an institution, 
they simply explain the fact by the fear and jealousy of 
mankind in general, aud continue to cultivate their ideas 
and discoveries. Their final destiny is inchoate delusions 
of grandeur, confusion and dementia. The forensic impor- 
tance of this class is great indeed, as they often do not stop 
at words, or mischief making, but keep on to deeds such as 
attempts to murder those in power, mistaking the represen- 
tatives of a system for the system itself. The true punish- 
ment for such "political murderers" is the asylum. They 
do not fear death as it stamps them as martyrs in the eyes 
of their followers. The murderers who attack rulers^ 
ministers and others in power from personal motives are not 
members of this class. These belong usually to the classes 
of paranoia persecutoria or querulans, although mixed forms 
are possible. The author then gives a number of examples, 
the most prominent of which is Guiteau. 

G. J. KAUMHEIMBR. 

Simulation of Insanity is the title of an original article 
by Dr. M. Holmboe in the February number of the " Norsk 
Mag. f. Lsegevidenskaben". " Paul Zacchias, the founder of 
criminal psychiatry, taught, in 1650, that : " no disease is 
simulated more often and more easily than insanity." This 
teaching was the guide for physicians and judges in the 
diagnosis and disposal of doubtful psychic conditions, more 
especially in criminals, for a long period, and as is the case- 
with many other old errors of science, this belief is firmly 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 367 

fixed in minds of the laity of our day. At present, 
psychiatry views the question of frequency of simulation 
from a different standpoint. We know that, in normal 
individuals at least, it is not frequent ; the idea of being 
considered and treated as insane is repugnant, and insanity 
is very difficult of successful simulation. The typical forms 
of insanity have disease-pictures limited to certain fixed 
bounds, even if pursuing very variable courses, that stamp 
the whole personality of the individual ; and the atypical 
course pursuing degenerative forms have hereditary or at 
least very early developed signs of an abnormal mental, and 
often also physical organization. To feign insanity success- 
fully requires not only a knowledge of the symptoms of the 
types of insanity — which can only be acquired by thorough 
study or long association with the insane — but also a 
coordinative ability, a domination of self, and an endurance, 
which is far from common. The simulator must, says 
Krafft-Ebing, be both poet and actor. Jessen and Schiile 
seem strongly to doubt that normal individuals can simulate 
insanity. The latter, with fifteen years experience as an 
alienist with several thousands of insane, claims not to have 
seen a single case. Leppmann says: "a consistent simula- 
tion of insanity, at least when continued over a considerable 
period of time, is such a rare exception that it hardly 
deserves consideration." Hoffman {Handbook of Forensic 
Medicine), gives the subject but very little consideration. 
On the other hand, Binswanger, in the years 1880 and 1881, 
found 21 simulators in 73 criminals committed to the 
Charite. Fiirstner, at Heidelberg clinic, found 12 in 25 
observation patients. Snell has reported six cases. Lom- 
broso found 13 in 300 insane criminals. The Danish 
alienist, Dr. Selmer, reported 5 cases out of 65 criminal 
patients. In Rotvold Asylum in twelve years I, have 
only seen one case of pure simulation out of twelve criminals 
placed here for observation. All observers are seemingly 
agreed that simulation is more common in individuals more 
or less abnormal, than in persons psychically intact. In 
certain forms of insanity there is a tendency to exaggeration 
and simulation of certain symptoms, that belong to the 
disease. I will only remind the reader of hysteria and 
Hecker's "Hebephrenic" (Jugendirrsinn). In every 
hospital for the insane is known the common, sudden 
outbursts of violent symptoms, in certain patients, whenever 
something is to be done with them they do not like. An 



368 psychological. [March-June, 

expert should approach a doubtful case, not to discover if 
lie be simulating, but if he be insane or not. Experience 
teaches that the following forms are most often chosen for 
imitation. (Fiirstner). (a.) Apathetic dementia, with either 
complete dumbness, or with amnesia and perversion of 
speech, writing and action, (b.) Attacks of excitement or 
unconsciousness, often accompanied by hallucination, which 
are continually referred to as having existed at the time the 
crime was committed, (c.) Maniacal conditions with violent 
and destructive tendencies. This form is oftenest adopted 
by persons suffering from other psychic anomalies, (d.) All 
sorts of varying indefinite symptoms, which are not to be 
classed under any special disease form. In the examination, 
mode of onset, symptom-complex, exaggeration and presence 
of anomalous symptoms, the adoption of symptoms by sug- 
gestion, hallucinations of sight, instead of the commoner 
ones of hearing and feeling, and above all, the absence of 
sleeplessness in maniacal simulation, the condition of 
nutrition and body-weight when a sufficiency of food is 
consumed, and the condition of the skin, circulation, and 
respiration are points to be carefully observed and weighed. 
The question of mania traasitoria is one of the most difficult 
problems the forensic physician is called upon to settle. 
Apart from poisoning by alcohol, carbonic-oxide, illuminat- 
ing gas and lead, attacks of temporary manical exaltation 
with consequent defect of memory principally occur in 
epileptics, either consequent upon an attack or vicariously. 
The physician must here, by repeated examinations into the 
anamnesis, satisfy himself as to the presence of an intoxica- 
tion or an epilepsy. A person suspected of simulation 
should be placed under constant observation, day and night, 
in an insane or general hospital as soon as possible, and 
should decidedly not be isolated unless by reason of exces- 
sive violence. There are certain cases of psychic degenera- 
tion in which simulation and true abnormalities are so 
interwoven that it is impossible to accurately analyze the 
condition. Here the examiner should frankly acknowledge 
his inability to accurately determine the condition." The 
author reports three illustrative cases under observation at 
Rotvold asylum. 1. One of pure simulation in a forger. 2. 
One of simulation in a defective individual, who afterwards 
became insane upon recommitment to prison. 3. One of 
actual mania, suspected by the prison-physicians to be 
simulation. " The first case most nearly resembled 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 369 

melancholia with stupor; the first probably real enough, 
being brought on by the shame of arrest and confinement, 
the second could not be successfully maintained under the 
constant surveillance at the hospital and therefore disap- 
peared quickly. When the physicians then informed him 
that in their opinion he was simulating he freely confessed 
it and served out his sentence. The second case is of 
interest because it shows that the distance between actual 
insanity and simulation in defective individuals is not very 
great. The depressing influence of lonely confinement in 
prison causing him to one day simulate insanity and the 
next to suffer from an actual melancholia, with an exag- 
geration perhaps of certain symptoms. The third case is 
not the only instance I have had occasion to observe where 
an attack of acute insanity in a prisoner serving sentence, 
has aroused suspicion of simulation, which later on proved 
erroneous, and illustrates the necessity of constant 
surveillance, mainly that the presence or absence of sleep- 
lessness can with certainty be determined." 

HALDOR SNEVE. 



Relation op Alcohol to the Inhibitions. — Dr. H. N. 
Moyer calls attention to the power of alcohol to weaken 
conscious control over the higher faculties, allowing the 
lower to act unchecked. In mental disease there is more or 
less loss of self control and alcohol has marked effect in such 
by still further weakening control and leaving morbid 
tendencies more free to act. People who are only partially 
insane are often made violent and dangerous by slight 
alcoholic indulgence. (Alienist and Neurologist, Jan., 1893.) 



Dipsomania. — Dr. J. Luys (Annates de Psychiatrie et 
d'Hypnot. Feb. 1893) claims that the periodicy of dipsomania 
is due to an interference with cerebellar innervation and 
that alcoholism, in cases where this does not occur, does not 
assume this periodic type. The opinion is based on hypo- 
thetical assumptions as to cerebellar functions. 

J. G. KIERNAN. 

Mental Confusion. — Dr. Charpentier under this title 
describes (Rev. Internt. de Biblio. Med., Jan. 25) a mental 
state characterized by perturbation in the ideational sphere,, 
consciousness, absence of delusion, and co-existence of 
inquietude. Often it cannot but be considered as an almost 



370 psychological. [March-June> 

physiological state resultant on passage from slumber to 
wakefulness in all adynamic states or cerebral congestive 
conditions. It may appear at the onset of many psychoses,, 
as well as among chronic vesanias and epileptics. In all 
cases, however, the concomitant psychic phenomena (hallu- 
cinations, amnesia, stupor, mutism) mark the picture of 
mental confusion. It may exist alone, and constitute by its 
duration, a true pathological state. It is a rapid disordered 
progress of ideas before consciousness, preserved, but 
astonished and restless. The ideas are not erroneous but so 
varied and tumultous in their course and so numerous that 
their numbers and disarray confounds the patient, who, 
incapable of directing his ideas although preserving his 
consciousness, falls into profound inquietude. Mental con- 
fusion has been styled, obvilutation, torpor, hebetude, intel- 
lectual vertigo and ideational chorea. What renders the 
case difficult is the fact that the patient renders an exact 
account of it only when cured. Furthermore they are apt 
to analyze the mental state they have experienced, and for 
the patient merely to describe this mental state does not 
suffice to reproduce it. How can, therefore, mental confusion 
be determined in patient who does not complain of it? Dr. 
Charpentier states that answers to simple terse questions 
(age, birthplace, colors) will indicate presence of attention 
but may appear incoherent because of rapid ideation. Usually 
the patients seem stupid. This is often the case with young 
female dyspeptics. Often mental confusion occurs in the 
morning after an insomnic night, a slumber too profound 
and prolonged or consecutive to excess. The patient appear 
lost ; acts without will or without taking account of his acts. 
Mental confusion among the insane is found chiefly among 
the acute confusional lunatics or the convalescent ; when it 
exists among these last they cannot be regarded as cured. 
Diagnosis is made only after recovery. Mental confusion 
should be distinguished from temporal mental enfeeblement 
of intoxications or infections (in these last there is a 
parallel enfeeblement of consciousness or absence of 
inquietude); from stupor (mutism, loss of consciousness of 
surroundings) and from vertigo (loss of consciousness and 
from involuntary movements). Mental confusion of pro- 
longed or frequently recurrent type has a bad prognosis. It 
occurs in paretic dementia, chronic persecutional vesanias 
and precocious dementia. It may be produced by sugges- 
tion, intimidation or surprise. j, G . kiernan. 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 371 

Delusions of Persecution. — At a meeting of the East 
German Pscych. Society, Neisser reported the case of a man 
aged 43 years who had delusions of persecution; he had 
been poisoned, attempts had been made to kill him, etc. 
He had been suffering from these delusions for many 
months, otherwise he was perfectly normal, conversed 
naturally and occupied his time with work. The case 
teaches .that the claim of many authors that paranoia is 
characterized by fixed delusions of persecution is not broad 
■enough to serve as a definition for the disease. Paranoia 
consists essentially in the tendency to evolve delusions of 
persecution. If a paranoiac could suddenly be robbed of all 
his delusions he would still be insane and in a short time he 
would have a new set of delusions. The diagnosis of 
paranoia is therefore dependent upon the demonstration of 
the tendency to form delusions. In the reported case this 
was entirely wanting. The existing delusions were probably 
the sequelae of some acute disease with delirium, possibly 
some organic disease of the brain, the result of syphilis. 
(AUgemeine Zeitsch.fiir Psychiatrie, Vol. 94, No. 3.) 

JOS. KAHN. 



Symptoms of Mental Dissolution. — Dr. Savage read a 
paper with the above title before the Medical Society of 
London. He took as the basis of his paper chiefly his 
experience of seventeen years at Bethlehem Hospital, giving 
tables of all patients over sixty. These tables were only 
useful as general indicators of the way in which senile dis- 
solution showed itself. Herbert Spencer had shown the 
uses of the study of mental dissolution as well as mental 
evolution. Natural decay followed certain lines but these 
differed in individuals. Premature decay occurred in 
certain diseases such as general paralysis of the insane, and 
also followed certain toxic conditions such as those due to 
alchohol. No single symptom was pathognomonic of dis- 
solution, though loss of memory was the most common. In 
all stages of mental dissolution was loss of mental power 
which might be shown in different ways and in different 
degrees. There might be loss of power or loss of control. 
Dissolution was shown early by reduced power of acquisi- 
tion, next by reduction of power of retention of recent 
impressions, next by defect of coordination, later by loss of 
control and of judgment. Dissolution was on the whole the 
reverse of evolution but did not follow same lines. He 



372 psychological. [March-June, 

began by an outline study of dissolution as seen in general 
paralysis of the insane, next with disorders of control of the 
general kind, such as hysteria, epilepsy, mania, melancholia 
and dementia. Taking the* groups of symptoms before the 
individual ones he specially noted the danger of impulse in 
the maniacal and of suicide in the melancholic states. As 
to special or individual symptoms sudden loss of memory 
of recent events was most important, loss of emotional 
control next in frequency and even more important, as 
leading to sexual faults. There was a tendency to collect 
objects of all kinds, which might depend on several causes. 
Frequently a disregard of cleanliness which was hard to 
understand. Judgment might remain for a long time 
after the memory was weakened and the control defective. 
{Lancet, March 25, 1893.) 

B. M. CAPLES. 

Mental Symptoms in Paramyoclonus Multiplex. — Dr. 
Lemoine de Lille {Bull. Med. du Nord., Sept., 1892) reports a 
case of paromyoclonus multiplex in which peculiar mental 
symptoms were present. These were allied to those of the 
choreics and the victims of echolalia and echoskinesia and 
of the " tic " disorder described by Guinon and Gilles de la 
Tourette. This observation, tends, in Dr. Lemoine's judg- 
ment, to support his opinion that it belongs among the choreas 
and is a variety — not a genus. 



Intermittent Melancholia. — Schubert reported the case 
of a woman aged 40 years, of good family history, who for a 
year and a half presented the symptoms of melancholia. 
Then the disease changed and took on an intermittent type. 
One day she would be depressed and irritable, the next day 
she would be apparently well. When she was discharged 
after a year's treatment the intermittent melancholia was 
still present, but on the so-called bad days the depression 
was not so marked as it had been. While at home the 
improvement continued but her intellect always remained 
weakened. (Allgemeine Zeitsch. fur Psychiatrie, Vol. 49, No. 3.) 



JOS. KAHN. 



Sexual Perversion Among the Insane. — Dr. Edw. 
Toulouse concludes after a critical analysis (La ,Trib. Med. 
Mch. 16, 1893) that sexual perversion is pretty frequent 
among the insane. For purposes of study cases should be 



1893.] PATHOLOGY AND SYMPTOMATOLOGY. 373 

divided into ideas of perversion and acts of perversion. 
Neither by itself is psychopathic, but both are far from 
infrequently met with in the insane, especially the degener- 
ate. Ideas are more frequent among the insane than acts, 
probably because hospitals exercise an intribitory influence. 
Sexual perversions may be the basis of delusions and be either 
systematized or non-systematized. Krafft-Ebing (Psychopa- 
thic/, Sexualis, Chaddock's Translation) had previously made 
the same distinction. 



Negational Insanity. — Negational delusional states, 
according to Dr. Edw. Toulouse (Gaz. des Hop., March 16, 
1893) constitute a symptom-complex which requires for its 
evolution certain psycho-physiological conditions. Cotard 
has wrongly attempted to make of these delusional states a 
special psychosis, developing in anxious melancholiacs and 
terminating in particular form of megalomania. Dr. Edw. 
Toulouse considers there are two classes, one is a system- 
atizated delusional. The other is an unsystematized 
delusional condition. The first occurs in melancholia and 
other psychoses. The last is limited to the systematized 
delusional psychoses. 

_______ J. G. KIERNAN. 

Some Notes on Scotch Asylums. — Dr. C. Eugene Riggs 
gives some notes of personal observations of the Scotch insti- 
tutions. There are six groups into which institutions for the 
insane in Scotland may be divided : First, Royal and Dis- 
trict Asylums; second, Private Asylums; third, Parochial 
Asylums; fourth, Lunatic Wards of Poorhouses; fifth, 
Training Schools for Imbecile Children ; sixth, the Depart- 
ment for Criminal or State Patients in the General Prison. 
In Scotland about 24 per cent of all the insane are boarded 
out. Not more than four patients are permitted in one 
family. At the Barony Parochial Asylum at Lenzie, a 
suburb of Glasgow, the doctor found that no doors were 
locked in the asylum and that open grates were burning in 
the wards without screens. • Dr. Riggs naturally speaks 
enthusiastically of Dr. Clouston of the Edinburgh Asylum. 
Speaking of restraint in this institution the Doctor says they 
use gloves and " a jacket whose sleeves are fastened to the 
body of it." In motor excitement Dr. Clouston regards 
hyoscine as the best agent. Dr. Howden of the Montrose 



374 psychological. [March-June, 

Royal Asylum stated that he had tried hypnotism on his 
patients and had found it only useful in insanity of a 
hysterical character. (Minnesota Hospital Bulletin.) 



THERAPEUTICS. 



Psychic Results of Chloralose Taking. — Dr. Richet 
has (La Trib. Med., Feb. 21) found that chloralose given in 
two decigram dose to the kilogram of weight produces verbal 
. blindness without interference with taste, hearing and 
smell. Tactile sensibility and sensitiveness to pain are 
abolished. Richet removed the gray substance of the cat's 
brain. Under such conditions the subjacent convolution is 
less excitable. When chloralose was given, this was more 
excitable. Dr. Laborde said that all substances causing 
hypnosis through action on gray matter had the like effect. 

J. G. KIERNAN. 

Chlorobrom in Mental Diseases. — The excellent results 
obtained by the judicious use of "chlorobrom," introduced by 
Professor Charteris for the prevention and alleviation of 
sea-sickness, have been recently recorded in medical papers. 
As a hypnotic in melancholia and the allied mental condi- 
tions Dr. Keay has found chlorobrom reliable, pleasant to take, 
and free from risk and disagreeable after effects. In 
threatened melancholia, brain exhaustion, or breakdown, 
so commonly occurring in overworked and worried business 
men, insomnia is usually such an obstinate and painful 
symptom that the use of the r^pnotic cannot be avoided. 
He prescribes an ounce of chlorobrom to be taken an hour 
before retiring. He finds that a sound sleep lasting from 
six to eight hours is almost invariably produced ; that it is 
not followed by sickness, headache, or lassitude the next 
morning; that the stomach and bowels are not deranged, 
and that there is no impairment of nutrition even when the 
drug is given regularly for weeks. Another form of mental 
depression in which he has found chlorobrom valuable is 
the excited or motor variety of melancholia. It combines 
the sedative with the purely hypnotic action and acts like 
paraldehyde when given with bromidia or one of the 
bromides. When the excitement is considerable an ounce 
and a half to two ounces may be given. He has never known 



1893.] THERAPEUTICS. 375 

unpleasant results to follow. One ounce represents thirty 
grains of chloralamid and thirty grains of bromide of 
potassium. Its discontinuance is not followed by any 
morbid craving. {Lancet, Mch. 18, 1893.) 

B. IT. CAPLES. 

Thymacetin in Insanity. — Dr. Morandan de Monteyel 
[Rev. gen. de Iherap., Jan. 30) concludes that thymacetin is 
without action on the different sensibilities, slumber, intellect, 
vaso-motor system, genital organs, secretions or intestines. 
In some cases, while without action on other reflexes, it 
causes double pupillary dilation, of half an hour's duration, 
during the first hour after taking. Thymacetin sometimes 
produces staggering and intoxication of short duration soon 
after taking. In three-quarter of the cases it occasions 
slight headache of several hours duration, usually coming 
on in the afternoon ; rarely at night or on waking. Thy- 
macetin increases muscular power for two hours after 
taking. It raises the temperature, sometimes by one degree. 
The rise and fall are gradual. It increases during two hours 
the number of inspirations without interfering with their 
rhythm. It increases for the same time arterial tension and 
number of pulsations without producing cardiac palpitations. 
In two-third the cases the use of thymacetin is followed by 
lassitude in the afternoon after taking, which may last till 
the next morning. Thymacetin in all de Monteyel's cases 
modified urination in three ways, it accelerated or altered 
the desire to urinate. It determined a urethro-vesical spasm 
or momentary retention or dysuria which were equally 
prompt in onset or disappearance. It sometimes occasioned, 
during passage of the urine, momentary urethral tingling 
almost amounting to burning. All these actions may be 
single or combined. Exceptionally it also causes ureteral 
pain. It causes, in two-third the cases, a bitter taste in the 
mouth with coated tongue but without effect on the breath. 
It usually causes an epigastric pain, often localized. It may 
produce persistent active thirst, nausea, vomiting, even 
gastric embarassment, coming on after discontinuance of the 
remedy. Other than with the stomach habituation to the 
remedy is rapid, but the stomach becomes more and more 
sensitive. Paretic dements are least affected. They do not 
suffer from anything but urethral or ureteral symptoms and 
these are less frequent than among the vesaniacs. 

J r G. KIERNAN. 



376 \ psychological. [March-June, 

Adjuncts to Medical Treatment in Hospitals for the 
Insane. — Dr. M. J. White says very little is to be hoped for 
in the relief of insanity by medical treatment alone. He 
advises moral suasion, homelike surroundings, vigorous 
exercise, Turkish baths, music, amusements etc. (Am. Jour, 
of Insanity, Apr, '93.) 

Hydrotherapy in the Treatment of Nervous and 
Mental Diseases. — Dr. Frederick Peterson has an interest- 
ing article on this subject in the American Jov/mal of the 
Medical Sciences for February. Concerning the principles 
which govern the application of hydrotherapy he says : 
The following are the ordinary effects to be borne in mind 
in the application of hydrotherapy to disorders of the mind 
and nervous system : 1. Cold and warm baths affect the 
central nervous system in a reflex manner by stimulating 
the sensory nerves of the skin and the vasomotor nerves, 
and thus influencing the cerebral circulation. Cold excites 
and warmth diminishes irritability when thus applied. 2. 
Short cold baths, especially when combined with sprinkling, 
showering, or rubbing, are powerfully stimulating, exhilarat- 
ing, and tonic. 3. Prolonged warm baths, steam and hot- 
air baths, and the hot pack, are relaxing, fatiguing and 
soporific. 4. A cold bath stimulates various reflexes in the 
body, such as peristalsis and the visceral reflexes in the 
sacral portion of the spinal cord. 5. Warm baths, by 
soothing peripheral nerve irritability, exert a calmative 
influence over the central nervous system. They mitigate 
reflex spasm and contractions in voluntary or involuntary 
muscle. 6. Cold applications to the skin stimulate vaso- 
dilator nerves, dilate the peripheral vessels, and increase 
blood-pressure. Warm applications also dilate superficial 
capillaries, but by diminishing the tone of the vessel walls 
they also reduce arterial tension. 7. To lower the irritab- 
ility of individual nerves or of the entire nervous system, 
prolonged warm baths or the hot pack are indicated. 8. 
As many hydrotherapeutic measures tend to reduce 
temperature, it is important to remember that in non-febrile 
cases, in anaemic conditions, and in debilitated states, the 
temperature must be raised artificially before subjecting 
patients to hydriatric treatment. In some cases the 
temperature of the body on rising from bed in the morning 
is sufficient ; in others a short stay in the hot-box may be 
needed. The following is an extract of his state- 



1893.] THERAPEUTICS. 37T 

ments in regard to indications for its use and 
the diseases to which it is applicable : Indica- 
tions and Methods. For tonic and refreshing effects. — 
A cold rain-bath (50° to 70 Q ), the patient rubbing himself 
while in the bath. Duration five to ten seconds ; or the 
half-bath in a tub at 65° to 75 Q Fahr., ten to thirty minutes. 
By "half-bath" is meant only six to eight inches of water in the 
tub, in which the patient lies and splashes about and is 
rubbed by an attendant. The object in both is to get the 
exhilarating and stimulating effects of the cold, and also the 
mechanical effect of the water impinging upon the skin. 
Such a bath should be taken every morning. For powerful 
tonic, revulsive, and derivative effects.-The cold douche increases 
reflex excitability, and causes hyperasthesia of the skin. It 
is a powerful stimulus, mental and physical. By means of 
various nozzles it may be ejected in the form of a jet, a 
spray, a shower, a fan, and by alternating with hot and cold 
water we have what is known as the Scotch douche. Such 
procedures are indicated in lethargic and hysterical forms of 
insanity, where there is sluggishness of the intellect, apathy, 
stupor, catalepsy, etc., and in melancholic cases, and in all 
cases where there is anaemia, chlorosis or gastric disorders. 
To produce sleep. The prolonged warm whole bath is indi- 
cated. Temperature 70°-90°. Duration, one-half to two 
hours. When of long duration the patient may be 
suspended in a hammock made of a sheet. Indicated in 
cases of melancholia with excitement and in some maniacal 
conditions. As a general hypnotic agent, however, appli- 
cable to all forms of insomnia among the insane, the hot wet 
pack stands foremost. It is applied in this way : A blanket 
9 by 9 feet is spread upon the patient's bed, and upon this a 
sheet wrung out dry after dipping in hot water is laid. The 
patient lies down upon this, and the sheet is at once evenly 
arranged f about and pressed around the whole body with 
the exception of the head, after which the blanket is also 
immediately likewise closely adjusted to every part of the 
patient's body. Other dry blankets may now be added as 
seems necessary. The patient remains in this an hour or 
longer; all night if asleep. Maniacal excitement. In this 
condition we all know how important it is to control motor 
excitement as much as possible in order to prevent the 
metabolic waste that progresses only too rapidly in many 
cases, often leading to death from exhaustion in a few days. 
Formerly we were accustomed to fasten the patient in bed 



378 , psychological. [March-June, 

with a strait-jacket, and dose with hyoscyamine liberally, 
and this treatment undoubtedly saved many lives, 
but the fastening in bed has been to a great extent tabooed 
of late years. It is astonishing to note the good effects of 
hydrotherapy in many cases oi this kind. The measures to 
be carried out are those indicated for insomnia. It is not 
often that patients laboring under great excitement can be 
placed in the warm bath, but the wet pack is applicable in 
nearly every case. It not only diminishes the erethism, but 
often brings about refreshing sleep, and always when kept 
applied prevents metabolic waste by motor excitement. I 
know of nothing that gives one better results in such cases 
than the wet pack in conjunction with overfeeding and 
occasional doses of hyoscyamine or duboisine if needed. 
Congestive headaches. These headaches are quite common 
among the insane, and one of the best hydriatric procedures 
for their relief is a running water cold foot bath every even- 
ing. The object is to dilate the vessels in the feet, to derive 
the blood from superior parts. One must, therefore, 
prescribe a prolonged foot-bath, accompanied by rubbing 
and chafing of the feet for the mechanical effects of the 
water ; or a strong fan douche of cold water applied to the 
feet very soon dilates the vessels and warms and reddens 
the feet. Actual experiment has shown that the tempera- 
ture in the auditory meatus is lowered as much as one 
degree by a cold foot bath, and conjunctival vessels have 
been observed to contract. Constipation. In the atonic con- 
dition of the intestines in most cases of melancholia and in 
some other forms of insanity, a powerful stimulus to 
peristalsis will be found in pouring water over the abdomen 
when the patient is in a tonic half-bath of low temperature. 
Application of Hydrotherapy in Nervous Diseases. The 
methods of using hydriatric measures for the pur- 
pose of a powerful nervine tonic and derivative 
and to produce sleep and soothe nervous excite- 
ment and irritability, have been described above. 
I will add here some of the special indications in various 
nervous disorders in a brief and practical summary, alpha- 
betically arranged. Anaesthesia (cutaneous). Short cold jet 
and fan douches of strong pressure to the anaesthetic areas. 
Temperature, 50° to 70°. Duration one minute. Daily. 
Angio-paralytic hyperidrosis of the feet. Prolonged cold foot- 
bath with chafing, or fan douche of cold water to the feet. 
Temperature, 60°. Duration twenty minutes for bath, five 



1893.] THERAPEUTICS. 379 

minutes for douche. Chorea. Cold plunge beginning at 90°, 
daily reducing until 70° is reached. If anaemic, spinal 
spray, jet or fan-douches, at first warm until patient becomes 
accustomed to them, then gradually reduced to 60° or 50° 
(Duval). Epilepsy. Cold shower baths and cold sponge bath 
daily are beneficial. The shower baths should be rain-like 
in character — that is, not too forcible. In many cases a 
morning and evening bath (the "half-bath") proves very 
serviceable. The "half bath" is taken in a bath-tub only 
half filled with water, and when taken should be accompan- 
ied by energetic rubbing of the patient by an attendant. 
This bath lasts five minutes, and the temperature should 
not be under .50° and not over 70° F. Where there is 
evidence of hypersemia and increased blood-pressure in the 
head, the cold cap is useful. While these are the general 
indications for hydrotherapy, certain measures are often of 
use at the time of seizures. During a fit or during a status 
epilepticus it will be observed that there is one of two vascular 
conditions present : either the face is pale and there are signs 
of brain anaemia, and in this case warm wet compresses 
should be applied to the head and genitals, accompanied by 
friction of the trunk upward, the body being placed with 
head low and arms uplifted ; or there is turgescence of 
vessels in the head, the face is red, the carotids beat 
strongly, and under such conditions a contrary procedure is 
indicated — cold compresses to the head, neck and genitals, 
strong wet beating of the feet, with a high position of the 
head. Daily applications for thirty seconds. Headaches, 
neuralgias, and migraines. If ansemic, heating cephalic com- 
presses (wring out thin linen bandages in very cold water; 
wrap head in capelline manner, and cover with one or two 
layers of dry linen or flannel). Apply at bedtime. Upon 
removal, envelope head in dry cloth and rub it dry. If 
hyperdemic, leg bandages (a piece of towelling a yard long is 
dipped in cold water at one end — one third — thoroughly 
wrung out and wrapped closely about each leg, so that the 
wet surface is next the skin and the dry portion envelopes 
the wet two or three times. Or, wet stockings may be put 
on and covered with dry towels). These are applied at 
bedtime and retained through the night. In many head- 
aches, especially of a congestive character, a prolonged cold 
foot-bath (twenty minutes, 60°) or the fan douche to the feet 
(five minutes, 60°) is very palliative. Hysteria. For erethetic 
type: Wet pack, 60° to ,70° for one hour or more, followed by 



380 psychological. - [March-June, 

massage (Putnam Jacobi); or the rain-bath at 75 Q to 65 Q for 
thirty-five seconds daily at twenty pounds pressure (Baruch). 
For depressed type: Cold affusions while standing in warm 
water, or hot-air bath, followed by rain-bath for thirty 
seconds at 85°, daily reducing until 60 Q is reached, this to 
be followed by spray douche for five seconds at 65°, or jet 
douche for three seconds at 65° to 55°. Reduce douche 
gradually to 50 Q or less, increasing pressure from two pounds 
to thirty (Baruch). Hypersesthesia (cutaneous). Long con- 
tinued cold douches to affected area. Daily twenty minutes 
at 70° to 80 Q . Insomnia. Wet pack ; see above. Impotence 
Brief cold sitz-baths. Daily, 56° to 64 Q , one to five minutes. 
The psychrophore, i. e., application to prostate of cold by a 
rubber condom or bladder secured over a rectal irrigator au 
double courant. Incontinence of urine. In paresis of sphincter 
or detrusor brief cold sitz-baths, daily 56° to 64°, one to five 
minutes. Cold rain-baths (50° to 60°) and douches as 
general tonics. In spasmus detrusorum vesicas, on the 
contrary, prolonged lukewarm sitz-baths, daily, thirty to 
sixty minutes, 70° to 90 Q . Locomotor ataxia. Prolonged 
warm baths, five to twenty minutes, 86° to 95° (Leyden). 
Hot-air baths to lower extremities followed bv affusions or 
douches,60° to 70° (Hceplein). Neuralgia of all types, especially 
tic. Hot-air bath, to perspiration, every other day, followed 
by gradually lowered douches (Baruch, Duval). Sciatica. 
Hot-air bath till patient perspires, followed by cold plunge^ 
or douche gradually lowered to 65°. Spinal cord affections. 
In various chronic diseases of the spinal cord the daily half- 
bath, 65° to 82°, six to ten minutes' duration, with affusion 
and chafing, will be found useful. In some cases of compres- 
sion and injury to the cord, in myelitis, and the like, where 
there is paralysis of the rectum and bladder and formation of 
bedsores or trophic lesions, resort may be had with advantage 
to the permanent bath (Riess). A sheet fastened in a bath- 
tub makes a hammock in which the patient lies at first for 
an hour or so daily, later all the time, except at night, when 
he is put to bed. The water is kept at a temperature agree- 
able to the patient (88°). Spinal irritation. " Douche fili- 
forme " as a rubefacient and epispastic along the spinal 
column ; or rain-baths, 65° to 85°, and douches. 
Spermatorrhoea. Cold sitz-baths, five to twenty minutes, 50° 
to 70°, daily at bedtime ; contra-indicated in sexual irrita- 
bility and active pollutions, where prolonged warm or hot 
sitz-baths at 90° to 98° should be used. Finally, I need 



1893.] THERAPEUTICS. 381 

scarcely say that if the alienist and neurologist are to make 
use of hydrotherapy at all, it must be borne in mind that 
precision of method is absolutely essential. As much care 
is necessary as in the prescription of drugs ; for. any viola- 
tion of the principles or neglect of the modes determined by 
long experiment and experience is certain to be followed 
by unfortunate results. 

Prevention of Suicide in the Insane. — Dr. Sutherland 
says that when we compare the number of patients who 
have suicidal tendencies with the actual number who 
commit suicide it must be confessed that we owe a heavy 
debt of gratitude to those whose skill and obedience this 
per cent, is reduced to so small a minimum. He thinks the 
relatives of the insane are responsible for the majority of 
suicides. They delay the admission of patients until some 
awful tragedy occurs; interfere unnecessarily with the 
treatment and endeavor to remove patients from care before 
they have properly recovered. Foolish relatives will often 
introduce pen knives, scissors, and other dangerous articles 
into asylum secretely, which are immediately taken away 
from the patients if the attendants know their work. It is 
only by careful and constant supervision that the number of 
suicides may be reduced to the minimum. A good superin- 
tendent will be particularly careful to instruct his staff to 
lock up all medicines, never allow patients to handle them 
and never serve out more than the exact dose indicated by 
the label on the bottle. These rules should apply to lotions, 
disinfectants, poisonous plasters, and especially pills, which 
the attendant must see that the patient swallows, or he may 
hoard up a poisonous quantity and take them all together. 
Keys must be worn on person, attached to attendant's wrist 
at night. Knives and forks used only in presence of 
an attendant, carefully counted before and after meals, 
locked up at other times ; fire irons and brooms secured in 
cupboard ; all broken glass and crockery immediately 
removed ; all outsiders, workmen, etc., must receive especial 
instructions not to leave dangerous tools and implements 
about. Suicides are recorded from eating arsenical putty 
and rat poison taken from pocket of attendant. A large 
proportion of suicides are due to hanging. All nails, wires, 
ropes, sash lines, bell pulls, tapes and strings must be 
removed from reach of patient. No parcel should be sent 
into the wards until contents are examined. Even a 



382 psychological. [March-June, 

piece of pencil or an old spoon may be used for purposes of 
strangulation. By attaching a handkerchief to one of 
these, pushing pencil through key-hole, pulling it taut and 
then making a noose, a gallows can be arranged quite as 
effective as any public executioner's. Patients will swallow 
almost anything, sleeve buttons, sleeve links, pieces of 
towel, india rubber utensils etc. He reports a case of a 
male patient who swallowed a billiard ball, which sticking 
in pharynx choked him before assistance could be procured. 
When walking patients may jump from bridges or throw 
themselves under a passing train. All doors should open 
outwards; windows should be protected by steel bars ; water 
closets must have neither bolts nor locks. Matches and all 
other inflammable material should be' carefully concealed, 
the taps for turning on gas must be shut up in cupboards 
for which only attendants have keys. Gas jets should be 
quite out of reach of inmates. Attempts at suicide may be 
made by strangling with the hands or thrusting the fingers 
down the throat. A commissioner of lunacy was once 
murdered by a patient with a large nail sharpened to a 
point and thus made into a dagger the handle of which 
was composed of a piece of old carpet. Dr. Orange once 
received a violent blow on the head from a lunatic w T ho 
used for his murderous purpose a large stone tied up in a 
stocking. If there is any doubt about the matter all patients 
should be considered suicidal until the contrary is known. 
Another frequent cause of suicide is where the relatives 
insist on removing the patient from the asylum before he is 
considered recovered by the authorities. Several cases are 
cited, one in which a man was taken home and cut his throat 
with a knife while at supper. (Lancet, Dec. 3, 1893.) 

B. M. CAPLHS. 

Treatment of Hysteria. — Modern ideas of Paul Blocq 
upon the psychic, external and internal treatment of hysteria 
appear in Med. Record, April 1. He regards hysteria, not as 
formerly considered — a general neurosis — but as a psychosis, 
ordinarily curable if appropriate measures are employed. 
The first thing to decide in hysteria and functional nervous 
disease is whether symptoms, especially psychic abnormities, 
are due to an imperfect organization, as determined by 
heredity and environment, or to operation on nervous 
system of a vitiated plasma. Defective organization, sub- 
oxidation and alterations in composition of blood, predis- 



1893.] THERAPEUTICS. 383 

pose to psychic disturbances. The various types of hysteria, 
the latent form, the minor, the major, mono-symptomatic 
require special consideration. In obstinate cases that resist 
all treatment, Blocq finds hypnotism a remedy next to 
isolation as a measure directed to the psychic condition. In 
latent or minor hysteria he emphatically protests against 
hypnotism ; in mono-symptomatic hysteria without convul- 
sive attacks, everything must be tried. He considers 
external treatment — hydrotherapy, electrotherapy, mechano- 
therapy — as next to psychic treatment. Cold affusion — 
douche or shower — once or twice daily most valuable of 
external measures ; cold pack or sponging may be substi- 
tuted ; sea bath of three minutes in mild climate admissible ; 
*faradism acts well in few cases, but the static current is most 
beneficial. Mechanotherapy, gymnastics, massage, systematic 
movements are beneficial. The internal use of bromide 
salts is useful only to aid in diagnosis between epilepsy and 
hysteria. Monobromide of camphor, pill form, three grammes 
three times a day has been well used. Valerian and 
valerianate of zinc or copper may give temporary relief. 
Active treatment during hysterical attacks, ether and the 
bromide of ethyl ; as narcotics use sulfonal or chloral ; 
because of frequent predisposition to morphinomania avoid 
opiates. Surgical interference only allowable when 
deformity due to fibro-tendinous shortening exists after 
spasmodic contracture. 

An Epidemic of Hysterical Convulsions Cured by 
Hypnotism. — Dr. L. Hirt reports an epidemic of hysterical 
convulsions in a village school. 20 girls out of 38 in one 
room, ranging from 5 to 12 years of age, were affected. All 
but three of them recovered during vacation with but 
slight treatment. These three, who were the first attacked, 
showed absolute inability to walk, and tremor, followed by 
convulsions, delirium and unconsciousness, the attack last- 
ing from one-half to three hours. These were cured by 
hypnotic suggestion. None of the 32 boys in the same 
room were affected. (Berlin. Klin. Wochenschr., No. 50, 1892.) 

G. J. KAUMHEIMER. 



Epilepsy Cured by Hypnotism. — Dr. Thomalla reports 
three cases of epilepsy of 12 to 17 years duration, the fre- 
quency of the convulsions varying from three per week to 
one a day, cured by hypnotic suggestion. In explanation 



3S4 psychological. [_Marcb— June, 

he assumes that the arterial spasm upon which the epilepsy 
depends is relaxed during hypnosis and that by repeated 
sittings this is intensified and made permanent. ( Wien. 
Med. Wochenschr.. Xo. 47, 1S92.) 

G. J. KAUMHEIMER. 



Hypnotism, Hypnotic Suggestion and Criminology. — 
Under this title Prof. W. Benedikt, of Vienna, publishes a 
characteristic article in Wien. Med. Wochensch., No. 44, 1892. 
He begins by pointing out that in 1SS9 he first raised his 
voice against the errors and extravagances of the modern 
science of hypnotism. '-'Suggestion therapeutics, with all its 
humbug and nonsense, has the advantage that ' traitment 
moral' remains as one of the resources of modern medicine, § 
although in the routine way it is used nowadays, it is use- 
less. Traitment moral requires a psychologist and thinker 
to conduct it." He denies that it has been proven that 
a crime was ever committed under the influence of hypnotic 
suggestion. Such things are done in experiments in the 
clinic or the parlor, but we have no data as to how often the 
subject "acts" in the fullest sense of the word. He also 
denies the possibility of such crimes. "A crime, especially 
of a professional character, requires a certain skill, which is 
the result of talent, teaching and practice, together with 
complete presence of mind and propitious circumstances." 
How can a hypnotizer foresee all the latter. "The question 
of the commission of crime through hypnotic suggestion and of the 
responsibility of such criminals, is wholly hypothetical" (italics 
the author's). That crimes can be committed upon hypno- 
tized subjects, B. does, of course, not deny. He absolutely 
disbelieves the many cures reported of alcoholism, morphin- 
ism, sexual perversions and other organic and functional 
troubles by this means. " The defenders of trial for witch- 
craft can give better grounds for their standpoint than the 
apostles of the criminal by suggestion and of the cure of 
incurables by this method. The further study of hypnotism 
should, for the present, be turned over to a small number of 
men who are mentallv and morallv fitted for it." 



G. J. KAUMHEIMER. 



1893.] EDITORIAL. 385 

EDITORIAL. 



The Narrowness of Professional Life. — A lady recently 
remarked in the hearing of the writer that as Dr. W. never 
* talked about medicine she could not think he knew much 
about it. Though her opinion of his attainments could not 
have been valuable, -by her remark she at least paid the 
doctor the compliment of appreciating the fitness of things. 
Many physicians, or some physicians, from ignorance of 
other subjects must either discuss medicine or keep silent, 
and so they bore people with professional incidents that 
have no interest for those who are not morbid, and fre- 
quently make their medical friends weary with recitations 
of "beautiful cases." We think this habit shows a scantiness 
of general information that is reprehensible in any physi- 
cian. A physician who is not ready on occasion to talk 
intelligently on politics, or discuss the recent progress of 
science, or pressing social questions, may be a competent 
physician, but he is neither an intelligent physician nor 
citizen. 

It is quite within the fact to say that there is no 
profession requiring more general information or broader 
views of things than that of medicine. Anatomy and 
physiology lead to the study of comparative anatomy and 
these include embryology. Materia medica should start 
from botany, chemistry and climatology inevitably lead to 
the study of geology, if one has the spirit of a student and 
cares to ask the why of things. There is scarcely any branch 
of knowledge unrelated to medicine and the physician who 
has high ideals and cares for the advantages of a well 
rounded life will broaden himself with liberal studies. In 
such studies, properly collateral to medicine, there are great 
practical advantages in addition to those not so immediately 
practical, by which various interests are added to life, and 
its enjoyment increased by widening the mental horizon. 
The success of the competent physician is largely due to 
constant and correct application to particular cases of the 



386 editorial. [March-June, 

conclusions from experience and study. Medicine, more 
than most professions, makes sudden and severe demands 
upon the judgment and the latter is certainly strengthened 
by exercise on subjects outside the narrow lines of technical 
knowledge. No one can make an excursion into outlying * 
regions of knowledge without coming back with his percep- 
tions sharpened by the journey, and in the case of the 
physician the advantages of having other interests that are 
educative, are very great, for in addition to the resulting 
mental development mentioned, one thereby gains truer 
views of professional subjects which otherwise would seem 
but dry and tasteless things. 

Another great advantage of this general culture 
is the fortunate mental habits which are developed, 
for not only the success but the pleasure of life 
depends largely upon mental habits. Habits of investiga- 
tion, habits of interest in many things that relieve the 
monotony of life, habits of interest in the world's progress, 
habits of hospitality toward new ideas, fondness for 
art, music, the drama, all these habits are educative 
in the highest sense and not only bring to life a 
higher order of pleasure, but they help to keep off that 
blight of pessimism that falls upon an old age of narrow 
interests. If we are to live the natural limit, old age is 
inevitable, and yet strangely enough most men dread it, and 
they dread it partly from the pessimistic coloring that many 
old people with their limited interests in life insist on giving 
it. If life is rightly utilized old age is no less enjoyable 
than earlier life though it has its special tastes and limita- 
tions. Youth has its enthusiasms that bring a quality of 
enjoyment that can never recur in life ; maturity its pleas- 
ures by the side of which those of youth seem simple and 
trivial, and as the autumn of life draws on there are 
pleasures none the less keen because the mental pace 
slackens and early enthusiasms sober. Each one of us is 
preparing himself for some kind of an old age, by his 
studies, his thinking and his mental methods. If we con- 



1893.] EDITORIAL. 387 

fine life to the hard and dull round of professional work, the 
day will come when, work being given up, life will be with- 
out interest. This result can be avoided by persistent 
habits of culture which, going beyond the narrow bounds of 
professionalism touch life at many points, making its 
decline not only full of interest, but happy and beautiful. 
Emerson said: "Let each day be the best," and he thereby 
showed the insight of a philosopher whose life exemplified 
his philosophy. By his mental elasticity, by his love of 
knowledge, by a persistent mental culture, he grew through- 
out his life. That such a life is a pattern for all is no 
idealistic rendering of a theory, but the sober statement of a 
fact. When we see, as we do, that such men struggle like 
others with the plain and homely facts of life, that they 
bear their part of care and disappointment with 
uncomplaining courage, and from their hard and common- 
place experiences build the fine structure of character ; when 
we see their modesty in success, their mental breadth, their 
largeness of life, we are encouraged to adopt mental methods 
and higher ideals that help life to broaden as it lengthens. 
If there is any man who can be specially benefitted by this 
mental broadening, it is the physician, if there is any one 
whose work affords the opportunity it is his. 



Mental Effects of Drugs. — The effects upon the nerv- 
ous system of stimulants and narcotics is a very interesting 
and important matter. It is a curious and interesting fact 
that almost every race of people makes use 6*f some stimu- 
lant or narcotic for purposes of inebriation. The savage 
finds relief from the monotony of his existence by occasion- 
ally imbibing his favorite liquor, and the civilized man 
finds a like relief from the tension and worry of life in the 
use of opium or alcohol. We do not believe that the uni- 
versality of such habits is evidence that there is a physiolo- 
gical demand for them, any more than the commoness of 
profanity is evidence that it is a necessary accompaniment 
of speech, or that the frequency of insanity or syphilis is a 



388 editorial. [March-June, 

reason for thinking them normal to the race. Men have 
simply taken advantage of what nature or art has put with- 
in their reach because they derive a certain amount of sens- 
ual pleasure from the indulgence. 

Physicians have long differed concerning the effects 
upon the nervous system of such substances as 
alcohol, tea, coffee, etc., and for this reason the 
recent experiments of Munsterberg, summarized in 
a recent issue of the Journal of Nervous and Mental Diseaset 
are of special interest. His experiments were with the drugs, 
opium, bromide of sodium, quinine, phenacetine, antipyrine, 
and such liquors as beer, cognac, Rhine and Bordeaux wine. 
The experiments related to tests of the auditory rnem#ry by 
requiring the subject to write down series of figures or con- 
sonants spoken to him, by adding series of figures, 
and also by naming colors and counting letters. Beginning 
first with alcoholic liquors he found that beer increased 
mistakes of recollection as much as 12 per cent in every 
case. After the stimulating effects had passed off it was 
found in some cases that the memory was better than usual. 
In regard to beer, cognac, Rhine wine and Bordeaux, the 
first was most inhibitory in its effects, the last less so. An- 
tipyrine increased the number of memory errors. The ac- 
tion of quinine was very variable. Tea always increased 
memory capacity, coffee in a less degree. Phenacetine in- 
creased normal memory, In efforts of simple addition, alco- 
hol sometimes increased and sometimes diminished the men- 
tal capacity, the results being contradictory. In the count- 
ing of letters a person who normally could count 406 letters 
in two minutes could, under the influence of beer, only count 
332. In naming colors alcohol, in nearly every case, was in- 
hibitory, while with tea and coflee the capacity was in- 
creased. The ability of letter counting per minute was in- 
creased about one-third by tea after the first hour and still 
more at the expiration of the second. In all these cases an- 
tipyrine, opium and bromide of sodium lessened capacity and 
phenacetine increased it. In the opium tests opium increased 



1893.] EDITORIAL. 389 

and bromide diminished capacity. Opium was only help- 
ful in one mental process, auditory memory, and bromide of 
sodium helpful in the simple process of addition. The re- 
sults of these experiments are the more valuable because of 
their substantial confirmation of medical experience every- 
where. Physicians are more and more of the opinion that 
the stimulating effects of alcoholics are transient and vari- 
able and they are now more ready than formerly to recog- 
nize that alcohol has a secondary effect that must also be 
reckoned with and this secondary or anaesthetic effect, now 
better understood, has had much to do with its diminished 
use. It is a law of therapeutic action that a small dose of a 
medicine has the opposite effect from a large dose and the 
effects of alcohol illustrate this law. The small dose, in 
some cases at least, quickens the heart throbs and excites 
the mental processes but larger doses depress the vital pro- 
cess and anaesthetize the nerve cells. This anaesthesia of 
alcohol is an important one to take into account, for it is the 
effect that it produces as it is commonly used. When a man's 
tongue is loosened by drink it is not always, as is supposed, 
because he is stimulated, but because self-restraint is weak- 
ened and this brake being taken off, the wheels of mentality 
turn unchecked. This, in place of being stimulation, is 
really anaesthesia, an early stage of alcoholic narcotism. 
Miinsterberg's observations with both tea and coffee are 
confirmed by common experience, though there are great 
individual differences. If there are any true physiological 
stimulants tea and coffee seem to deserve the title. 



Dr. Richard Dewey. — Last year there was a political 
revolution in Illinois and among other results, the public 
are now witnessing the " resignation " of various 
superintendents of public institutions. It is no ex- 
aggeration to say that Dr. Dewey possesses rare qualifica- 
tions for the position of superintendent of an insane 
hospital; long experience, executive ability, rare tact in 
dealing with the insane, delicacy of feeling, a fine sentiment, 



390 editorial. [March-June, 

and a mental elasticity that has survived the harsh and 
trying experiences of institution life. When the doctor 
went to Kankakee he inaugurated the method of cottage 
care of all classes of the insane upon a scale never before 
undertaken in this country. The difficulties he had to 
meet were such as no ordinary man could have successfully 
overcome ; but he was equal to the occasion, and with rare 
management, with patience and persistence and a quiet 
courage worthy of a better fate, he built up an institution 
that is considered a model not only in America but across 
the ocean. The doctor has located in Chicago with the in- 
tention of practicing his specialty and we wish him great 
success. 

Politicians and Bosses. — Politics should have nothing to 
do with the management of public institutions, for there, at 
least, its touch is death to good order and efficiency. The 
history of Insane Hospitals in this country shows that their 
usefulness has been impaired whenever party politics has 
interfered in their management. Indeed, no sensible man 
need be told that such would be the result. The future 
historian, when he sits in judgment on this age, will have a 
worrying task trying to reconcile our fine pretensions with 
our practice, whereby we build magnificent institutions for 
the dependent classes and then, in some instances at least, 
hand them over to the uses of the party boss. Concerning 
politics and politicians we do not agree with those who con- 
sider the latter a bad lot and politics necessarily disreputable, 
nor do we endorse the practice of calling honorable poli- 
ticians "bosses" and holding them up to ridicule. Here as 
elsewhere it is necessary to discriminate. For a politician 
properly so called we have a high respect. Some of the 
most honorable men we know are politicians, whose lives 
are clean and patriotic. The politician is essential to good 
government. Without him political order would be still a 
dream, and history a tale of unorganized and savage con- 
tests. 



1893.] EDITORIAL. 391 

That the term has been and is misapplied is unfor- 
tunate, and honorable public men have to suffer from its 
misuse. The term is wrongfully applied to party workers 
whose party relations are secondary to their personal inter- 
ests, men who are in no proper sense politicians, and who 
pretend to a political decency they neither themselves pos- 
sess nor appreciate in others. By sheer luck they sometimes 
occupy high positions, but their proper sphere is that of a 
ward boss where, though less conspicuous, they are active 
and often dictate the policy of those politically above them ; 
like Comanche Indians,they ambush honorable public officials 
who come within range of their political tomahawk. 

Of all God's creatures the insane are the most helpless and 
unfortunate. Deprived of everything which life prizes, pos- 
sessed by the torturing fancies of disease, yet keenly sensi- 
tive to their fate, they sit in helpless isolation appealing 
simply for justice and kindness. In view of this there is 
something coldly savage in the process by which these in- 
stitutions are sometimes tossed about from party to party as 
if the interest of the "politician" were superior to the rights 
of the inmates. 

In spite of the shock which is sometimes admin- 
istered to our faith, we firmly believe that the world 
is growing better, and that our politics moves with the pro- 
cession. We believe that the festering vices of our time, 
political and social, the crudities and cruelties and savagery 
that sometimes occupy high places in the social synagogue 
and wear the fair name of civilization, will disappear, and 
with them will go all that motley throng of evil things that 
thrive upon the cupidity or misfortunes of mankind. When 
that good time comes and the party boss is a thing of his- 
tory, he will serve only to point a moral to the civilized, who 
will wonder at the crude social state that made his calling 
and election possible. 

" Let us learn to labor and to wait." 



392 editorial. [March-June, 

Leucocytes and Bacteria. — In his address at Owen's 
College, Manchester, Dr. Broadbent spoke of the manner in 
which alcohol, chloral, and other substances may aid the 
fatal work of certain pathogenic microbes. It is well known 
that the leucocytes under certain conditions attack and 
destroy bacilli that would otherwise produce disease. The 
former are, therefore, a home guard, always on duty to at- 
tack and, if possible, destroy the foreign enemy. Inflamma- 
tion around a wound is a result of this conflict, the smoke of 
battle that shows that the leucocytes have met and are try- 
ing to destroy the invaders. If they fail the microbes pass 
on to the glands and here another battle ends in in- 
flammation or abscess, and if the leucocytes are again de- 
feated, general infection follows. This is not a theory, for 
many observers have actually seen leucocytes take bacteria 
into their interior and destroy them. It is known that cer- 
tain substances paralyze the action of leucocytes, entirely 
suspending their power to destroy bacteria. A rabbit after 
having bacteria injected under its skin has inflammation 
and perhaps an abscess at the spot, but recovers. Another 
rabbit has administered to it a similar injection and at the 
same time an injection of chloral. The chloral paralyzes 
the leucocytes, they do not destroy the bacteria and the 
rabbit dies. Alcohol has a similar effect so that it predis- 
poses to septic infection. Doyen found that guinea pigs 
died when cholera microbes were administered to them if 
at the same time alcohol was given. Dr. Ridge has shown 
that even such infinitesimal quantities of alcohol as one part to 
5,000 cause a more rapid multplication of bacteria, so that 
there is no longer any doubt that this substance renders the 
system more susceptible to microbic infection. 



Fatigue of Nerve Cells. — Dr. Hodges has continued 
his researches, noticed in a previous issue, on 
changes due to functional activity of nerve cell. 
He experimented by producing artificial fatigue 



1893.] ASYLUM AND HOSPITAL REPORTS. 393 

of ganglia of animals by electricity and also by 
observing the effects of normal fatigue. His observations 
show that the results of fatigue of nerve cells are easily 
demonstrable. As a result of fatigue the nucleus of a nerve 
cell decreases in size and assumes an irregular appearance. 
In the spinal ganglia the protoplasm of the cell shrinks and 
becomes vacuolated and in the cerebral and cerebellar cortex 
the shrinking is more marked. Under fatigue the cell 
protoplasm does hot stain so readily. After rest the normal 
structure of the cell is restored. The details of his investiga- 
tion are given in a recent issue of the Journal of Morphology. 
These studies are confirmatory of the view that nerve cells* 
if not the sole source, are certainly the chief source of nerve 
energy and show that its evolution and expenditure are 
processes the results of which are within the reach of obser- 
vation. Thus step by step do we encroach upon the 
territory of the unknown. Possibly some day we may be 
able to see the crash of molecules by the fall of which nerve 
energy is set free, or with the better methods and the 
sharpened vision of the coming scientist we may see the 
molecules as they are placed in position in unstable com- 
pounds, ready for the fall which liberates their imprisoned 
energy. 

ASYLUM AND HOSPITAL REPORTS. 



Fifth Annual Report of the Managers of the Utica State Hos- 
pital at Utica, for the year ending Sept. 30, 1892. — The number 
of patients admitted during the year were 345, and the total 
number treated 811. The recoveries computed on admis- 
sions are a little over 25%; computed on discharges they are 
a little over 30%. This reduced percentage is explained by 
the statement that Superintendents are now more careful to 
specify as recovered those whose mental poise has been en- 
tirely re-established. The Superintendent says, with com- 
mendable frankness and we think truly, that insanity is in 
the main a chronic disease. The Superintendent notices 
the completion and opening of the new group of infirmary 
buildings attached to the hospital, which will accommodate 



394 notes and comments. [March- June, 

about two hundred persons. In this department they have 
adopted the very sensible plan of having male and female 
patients dine in the same room. The training school for 
nurses of this institution has 59 on its roll of attendance. 

Seventh Biennial Report of the Trustees and Officers of the First 
Hospital, Saint Peter, for the Biennial Period Ending July 31, 
1892. — There were 599 patients in this hospital during the 
year, the whole number treated during the year being 1573. 
A training school for nurses is connected with this institu- 
tion. Since the report was written Dr. Bartlett has resigned. 

Fifth Biennial Report of the Northern Hospital for the Insane, 
Winnebago, Wis., for the Two Fiscal Years Ending Sept. 30, 
1892. — During this time 698 patients were admitted to the 
institution. The capacity of the hospital is 638. The Sup- 
erintendent very properly protests against the admission of 
epileptics into the insane hospitals. The death rate in this 
institution is gratifying ly low, being about 6%. Dr. Wegge, 
the superintendent, suggests that a cottage be built for the 
isolation of patients with infectious diseases. Such a build- 
ing as this should be attached to every public institution. 

Annual Report of the Asylum for Chronic Insane, Milwaukee 
County, for the Year Ending Sept. 30, 1892. — The annual re- 
port of Supt. Wilkins shows that at the close of the year 
there were 132 patients in the asylum. The asylum is 
thoroughly equipped and seems to be doing excellent work. 
The report of the medical officer, Dr. T. H. Hay, states that 
there have been only five deaths during the year, and in all 
these cases the ages ranged from 65 to 85 years. This is a 
compliment to Dr. Hay and to the management of the in- 
stitution. 

NOTES AND COMMENTS. , 

The lectures delivered by Dr. E. C. Seguin before the 
Medical Society of the University of Toronto, on Certain 
Questions in the Treatment of Neuroses have been translated 
into German by Dr. Wallach of Frankfort-on-the-Main, and 
published by G. Thieme, Leipzig. 

Dr. H. M. Bannister has translated the well-known work 
of Dr. E. Regis of Bordeaux, on Mental Medicine. The work 
is now in press at the Utica State Hospital. The work has 
had a large sale in Europe and we predict for it a hearty 
welcome from the Profession in this country. 



1893.] NOTES AND COMMENTS. 395 

Dr. Gibier states in the Therapeutic Review that he ex- 
amined microscopically some specimens of rags, imported 
from Bremen and " disinfected" by the government. Some 
of the pieces had on them spots of blood and pus indicating 
that they came from some hospital. Among numerous 
pathogenic bacteria found were those of erysipelas and he 
estimated that there were from 400,000,000 to 800,000,000 
living microbes per drachm of the rags examined. Inde- 
pendent of the special danger from cholera this year there 
is no excuse for the official carelessness that would at any 
time permit such disease-bearing material to enter the 
country. That the disinfection said to have been performed 
on these rags was inefficient is shown by the fact that 
torulse were found, for these can not survive longer than a 
few moments a temperature of 158 degrees F. 

In Dr. Forel's latest investigations on the ninth, tenth and 
twelfth nerves he ascertained that there is no crossed root in 
the motor part of these nerves as maintained by Obersteiner. 
The latter, in a recent issue of the Journal of Comparative 
Neurology, says that the distinction between ganglion cells 
and neurogia cells must be dropped, as there are probably 
cerebral histological elements intermediate between the two. 
Nans'en holds that the axis-cylinder consists in a number of 
closely arranged primitive tubes. These are composed of 
extremely fine connective tissue sheaths with viscous con- 
tents. This latter substance is the physiologically active 
part of the axis-cylinder. 

At the competitive examinations for the positions of 
internes at the Cook County Hospital there were 31 examined. 
Of the eight successful candidates, five were graduates of 
Rush, two of the Chicago Medical College, one of the College 
of Physicians and Surgeons. 

A hospital for epileptics is now open for the reception of 
patients in Philadelphia. It contains two general wards 
and nine separate rooms. Dr. Wharton Sinkler and Dr. 
Charles K. Mills are attendant physicians. 

Professorship of Mental Diseases. — The Trustees of the 
University of Pennsylvania have elected Dr. Chas. K. Mills 
Professor of Mental Diseases and of Medical Jurisprudence. 
The lectures on mental diseases will be chiefly clinical. Dr. 
Mills' large experience as a specialist in nervous and mental 



396 book reviews. [March-June, 

diseases has specially qualified him for the place and the 
appointment is a fitting reward of his high attainments. 
We congratulate the university in the wisdom of the choice. 



BOOK REVIEWS. 

Lectures on Mental Diseases, designed especially for 
Medical Students and General Practitioners, by Henry 
Putnam Stearns, A. M., M. D., Physician Superintendent of 
the Hartford Retreat, Lecturer on Mental Diseases in Yale 
University, Member of the American Medico-Psychological 
Association, Member of the New England Psychological 
Society, Honorary Member of the British Psychological 
Association, Honorary Member of the Boston Medico- Psy- 
chological Society, Member of the American Medical Associa- 
tion, etc., etc.; with Illustrations. Philadelphia: P. Blakis- 
ton, Son & Co., 1012 Walnut street. 1893. 

This volume comprises the lectures delivered by the 
author on Mental Diseases at Yale. The first two lectures 
are devoted to the physical basis of thought and hallucina- 
tions and illusions. The latter chapter is an excellent one, 
also the chapters on imperative concepts and delusions. 
The classification of mental disorders adopted is to be 
commended. We do not, however, see any good reason for 
calling paranoia " primary delusional insanity. " The 
description of various forms of mental disorder is excellent. 
The style is clear and forcible. As a whole the work is 
practical and answers the purpose excellently as a text 
book on mental disorders. We do not know of a better 
work for general practitioners or students of medicine than 
this one. 



A Practical Treatise on Materia Medica and Thera- 
peutics, with Especial Reference to the Clinical Appli- 
cation of Drugs, by John V. Shoemaker, A. M., M. D., 
Professor of Materia Medica, Pharmacology, Therapeutics, 
and Clinical Medicine, and Clinical Professor of Diseases of 
the Skin in the Medico-Chirurgical College of Philadelphia ; 
Physician to the Medico-Chirurgical Hospital ; Member of 
the American Medical Association, of the Pennsylvania and 
Minnesota State Medical Societies, the American Academy 
of Medicine, the British Medical Association ; Fellow of the 
Medical Society of London, etc., etc. Second Edition. 



1893.] BOOK REVIEWS. 397 

Thoroughly Revised. Two Volumes. Philadelphia and 
London: The F. A. Davis Co., publishers. 1893. 

These two volumes, comprising over a thousand pages, are 
a thorough and systematic exposition of the subject treated. 
There is hardly anything that the practical physician will 
want to know, from pharmacy to prescription writing, 
medical electricity and the therapeutics of drugs that can 
not be found in these pages. A long chapter on pharma- 
ceutical nomenclature and classification gives quite a full 
and systematic sketch of subjects and methods of this 
department. Likewise, the chapter on prescription writing 
is excellent. The chapter on electro-therapeutics is thor- 
oughly practical and is sufficiently full for all purposes. 
This alone will take the place of an ordinary volume on the 
subject. The author has also done well to introduce a 
chapter on massage and the rest cure. Chapters on pneumo- 
therapy and hydro-therapy are introduced. There is a 
section on mineral springs, climatology, diet in diseases, and 
on music. The second volume treats of the articles of 
materia medica more particularly and is systematic and, 
eminently practical. Altogether this is one of the most 
useful books that has been written on the subject and is one 
which no practical physician can afford to be without. 
Subjects are considered with sufficient fullness and yet a 
reasonable brevity is observed. Everything is systematically 
arranged and the style of the author is direct and clear. 
We recommend it as a model work upon the subject. 



PSYCHOPATHIA SEXUALIS, WITH ESPECIAL REFERENCE TO 

Contrary Sexual Instinct. — A. Medico-Legal Study. — Bv 
Dr. R. von Krafft-Ebing, Professor of Psychiatry and 
Neurology, University of Vienna. Authorized Translation of 
the Seventh Enlarged and Revised German Edition, by 
Chas. Gilbert Chaddock, M. D., Professor of Nervous and 
Mental Diseases, Marion-Sims College of Medicine, St. Louis ; 
etc. Philadelphia, 1893. The F. A. Davis Co. 

This is a work which will be read with interest and laid 
aside with mingled feelings, of pity for the unfortunate 
victims of a mental state they are in no wise responsible 
for ; of disgust at the depths of human depravity revealed. 
Not that the author deviates one iota from the strict line 
of his subject in order to introduce extraneous matter. The 



398 book reviews. [March-June, 

aberrations of the sexual sense, all over the civilized world, 
have been attributed by moralists and jurists to vice, pure 
and simple. It has been the work of Krafft-Ebing, above all 
others, to shpw that many of these delinquents were the 
victims of a degenerate ancestry, a vicious environment, or 
a congenital mental defect and that their practices were as 
natural to many of them as those of normal men are to 
these. The work, which is addressed " to earnest investiga- 
tors in the domain of natural science and jurisprudence" 
opens with a short consideration of the Psychology of the 
Sexual Life, followed by its. Physiology. The General 
Pathology, occupying nearly three hundred pages, is 
devoted to the consideration of the various clinical forms 
which sexual aberration may assume. Sexual anaesthesia, 
hyperaesthesia and paraesthesia, sadism and masochism in 
their various forms, .fetichism and homosexuality are the 
main clinical divisions. The last mentioned condition is 
especially illustrated by acute psychical analyses written by 
highly educated urnings. The chapter on Special Pathology 
comprises the pathological vita sexualis of the various 
psychoses. The author is. firmly convinced of the very 
great value of hypnotic suggestion in many cases of ac- 
quired sexual perversion even when a congenital taint 
underlies it and it must be said that his examples are con- 
vincing. Within a very recent period, a case of murder 
brought on by female homo-sexual love has attracted a 
good deal of attention. At the same time, two similar cases, 
one male and the other female, were reported in the daily 
press. Krafft-Ebing's work should be in the library of every 
prosecuting attorney in the country, as well as of every 
physician who is at all interested in mental or sexual 
diseases. The translator has done his work thoroughly, and 
has succeeded in preserving the style of the original in a 
marked degree. The mechanical execution of the work is 
good. A consideration of the legal aspects of sexual perver- 
sion in the light of Austrian, German and French statutes, 
closes the work, which is a monument of industrious glean- 
ing in a field heretofore but sparsely cultivated. It is to be 
expected that as the knowledge of this subject becomes more 
diffused in this country, numerous instances of perverse 
sexuality will be found. 

The Year-Book of Treatment for 1893, A Critical 
Review for Practicioners of Medicine and Surgery, by 



1893.] BOOK REVIEWS. 399 

twenty-two contributors. Philadelphia, 1893, Lea Bros, and 
Co. This little work, which is intended to be a compilation 
of the therapeutic advances found in periodical literature in 
1892, is the work of twenty-two well-known English medical 
men. One of the first things that will strike the attentive 
reader is the small number of American authors or periodicals 
quoted. While it is hardly to be expected that a complete 
resume of the therapeutic work of 1892 can be given in a 
volume of less than five hundred octavo pages, the informa- 
tion contained in the book is reliable and will be of great 
assistance both to the busy practicioner and the medical 
writer. 

We have received a circular announcing the early ap- 
pearance of the Revue Neurologique, a French journal to be 
issued twice a month under the editorial management of 
Drs. Brissaud and Marie. This journal, while it will have 
original articles, will be devoted generally to publications of 
abstracts and reviews of articles appearing in other journals. 
In other words, it is upon the plan of the Review of Insan- 
ity and Nervous Disease. We wish the new journal suc- 
cess, and have no doubt that it will meet with it. Current 
medical literature is so vast that it is absolutely necessary 
to a large number of physicians that it be obtained in some 
condensed form. Such journals answer this demand, and 
we believe the principle will be extended to other depart- 
ments of medicine. It certainly ought to be. Time is 
valuable, life is short, and we need our information packed 
into the smallest space possible. We, who are engaged in 
this packing process, are doing valuable missionary work. 



PAMPHLETS AND REPRINTS. 

Annual Report of the Asylum for Chronic Insane, Mil- 
waukee County. 

Fiftieth Annual Report of the Managers of the Utica State 
Hospital. 

Seventh Biennial Report of the Trustees and Officers of 
the First Hospital, Saint Peter, Minn. 

Fifth Biennial Report of the Northern Wisconsin Hospital 
for the Insane. 



400 pamphlets and reprints. [March-June ; 

The Neuropathic Constitution, Education and Marriage, 
as Factors in the Causation and Propagation of Nervous 
Diseases. — PuntoD . 

Modern Surgery in its Relation to Accident Insurance. — 
Oviatt. t 

Brain Surgery : Report of a case. — Schaefer. 

Vertebral Surgery, with Reports of Three Cases, and a 
New Method of Operating in the Dorsal Region. — Schaefer. 

The Sympathetic Nerve and Abdominal Brain in Gyne- 
cology. — Robinson. 

Skin Grafting upon the Cranium. — Schaefer. 

Report of a Case of Syringomyelia, with Exhibition of 
Sections of the Spinal Cord. — Lloyd. 

Traumatic Myelitis. — J. T. Eskridge. 

Report of a Case of Moral Imbecility, of the Opium Habit 
and of Feigning. — Eskridge. 

Modern Homeopathy, its Absurdities and Inconsistencies. 
Browning. 

A Case of Hemorrhagic Iritis with Remarks. — Ch. Zim- 
mermann. 

Bloodless Amputation at the Hip Joint by a New Method. 
— N. Senn. 

Syringomyelia. — Eskridge. 

The Value of Voltaic Alternatives in Optic Nerve Atrophy. 
— Riggs. 

Fifth Biennial Report of the State Board of Corrections 
and Charities of Minnesota. 

First Biennial Report of the State Board of Control of 
Wisconsin Reformatary, Charitable and Penal Institutions. 



NEW GERMAN LITERATURE. 

Wolf, M. Die physische und sittliche Entartung des modernen 

Weibes. Leipzig. A. Schupp. 
Behring. Die Blutserumtherapie II. Das Tetanusheilserum 

und seine Anwendung au) tetanuskranke Menschen. Leipzig. 

G. Thieme. 
Bum and Schnirer. Diagnostisches Lexikon fir praktische 

Aertze. Wien and Leipzig. Urban und Schwarzenberg. 



1893.] PAMPHLETS AND REPRINTS. 401 

Gad, J. Real-Lexikon der medicinischen Propddeutik. Wien 
and Leipzig. Urban und Schwarzenberg. 

Ziemmsen. Annalen der stddt. allgem. Krankenhduser zu 
Munchen, 1885-1889. Munchen. M. Rieger. 

Krafft-Ebing. Lehrbuch der gerichtlichen Psychopathologie. 
Third Edition. Stuttgart. F. Enke. 

Kaan, H. Der neurasthenische Angstajjed bei Zwangsvorstellungen. 
Leipzig and Wien. F. Deuticke. 

Gugl and Stichl. Neuropathologische Studien. Stuttgart. F. 
Enke. 

Strumpell. Lehrbuch der speciellen Pathologie u. Iherapie. 
Seventh Edition. Vol. II. Part I. Diseases of the 
Nervous System. Leipzig. F. C. W. Vogel. 

Knies, M. Die Beziehungen des Sehorgans und seiner Erkran- 
kungen zu den ubrigen Krankheiten des Kdrpers. Wiesbaden. 
J. F. Bergmann. 

Becker, R. Sammlung gtrichtsdrztlicher Gutachten. Berlin. 
S. Karger. 

Ascher, B. Zur staatlichen Beaufsichtigung der Irrenanstalten. 
Berlin. S. Karger. 

Baumgarten, E. Die Neurosen u. Reflexneurosen d. Nasen- 
rachenraumes. Sam ml. Klin. Vortr., No. 44. Leipzig. 
Breitkopf and Hartel. 

KoLLiCKER, Th. Ueber die Fortschritte der Operativen Ghirurgie 
des Ruckenmarks u. der peripherischen Nerven. Stuttgart. F. 
Enke. 

Kraepelin. Ueber die Beeinflussung einfacher psychischer 
Vorgmge durch einige Arzneimittel. Jena. G. Fischer. 

Lombroso and Lasche. Der politische Verbrecher und die 
Revolutionen. Translated by N. Kurella. Hamburg. 
Verlagsanstalt u. Druckerei A.-G. 

Ziegler. Beitr'dge z. patholog. Anatomie, etc. Bd. XII. Jena. 
G. Fischer. 

M bius. Abriss d. Lehre v. d. Nervenkrankheiten. Leipzig. 
Ambr. Abel (Arthur Meiner). 

Erste Sammlung der Schriften d. Gesellsch. f. Psycholog. 
Forschung. Leipzig. Ambr. Abel (Arthur Meiner). 
Consist of five numbers, each of which can be had 
separately: 



402 miscellaneous medical notes. [March-June, 

Heft I. Schrenck-Notzing. Die Bedeulung narkotischer Mittel 
fur den Hypnotismus, etc. Forel. Ein Gutachten uber e. 
Fall von spontanem Somnambulismus etc. 

Heft II. Munsterberg. Ueber Aufgaben und Methoden der 
Psychologie. 

Heft III and IV. Moll. Der Rapport in der Hypnose. 
Untersuchungen u. d. thierischen Magnetismus. 

Heft V. Koeber. Jean PauVs Seelenlehre. Offner. Die 
Psychologie Charles Bonnefs. 



MISCELLANEOUS MEDICAL NOTES. 



Piperazin. — Reports from the German Journals are 
quite favorable to this method for gouty affections. In the 
Berliner Klin. Woch., Doctors Biesenthal and Schmidt 
reported seven cases in which marked relief was obtained in 
several. In one case large quantities of gravel were passed 
the next day after using the remedy and immediate relief 
was experienced. The remedy should be given to the 
amount of 15 grs. a day, largely diluted. 

An interesting communication on the treatment of sea- 
sickness is made by Dr. George Macdonald, Glasgow. He 
states {Brit. Med. Jour., 1892, Sept. 17) that it was his custom 
to prescribe in these cases a mixture of potassium bromide 
and spirit of chloroform; although this proved useful in 
many cases, yet it had the objection of being exceedingly 
liable to rejection by the stomach. The combination of 
chloralamid and bromide of potassium ("chlorobrom") was 
however never rejected in his experience, while at the same 
time it seldom failed to allay gastric disturbance and induce 
refreshing sleep, from which the patient awoke with a clear 
head, fair appetite, and free from all disagreeable symptoms. 
He considered that the perfect safety, agreeable taste and 
freedom from disturbing after-effects of the remedy all 
combined to render it an admirable preparation and an 
ideal sedative. 

Lysol. — Attention having been drawn by the recent 
cholera "scare" to the popularity of carbolic acid as a 
disinfectant, notice is being taken in medical circles of 
the even superior advantages for many purposes of the 



1893.1 MISCELLANEOUS MEDICAL NOTES. 403 

cresols as disinfectants. It was discovered that crude 
carbolic acid made soluble by the action of sulphuric acid 
surpassed in germicidal power an equally strong solution of 
pure phenol, besides which creolin, although free from 
carbolic acid, was proved to be of unmistakably superior 
disinfecting activity to the latter. Being insoluble in water, 
however, these cresols were neglected until the idea was hit 
upon of combining them with resin soap. According to 
German testimony, lysol is one of the most precious products 
of coal tar which chemistry has given to the service of 
mankind. — Scientific American. 

Antiseptics and Disinfectants. — The prevention of 
disease is the unselfish mission of the modern physician. 
Antiseptics and disinfectants to-day occupy the first place in 
medical and surgical practice. Dilute solutions of acids have 
been strongly commended as preventive of cholera. The 
Liquid Acid Phosphate is an efficient agent in securing the 
desired condition of acidity. Copper Arsenite Tablet 
Triturates, j/f o -and ^ 000 grain, have been extensively and 
successfully used in dysentery and diarrhceal disorders and 
are indicated in cholera, both for specific action in con- 
trolling intestinal secretion and for relieving the profound 
anaemia. Eucalyptus and Thymol Antiseptic is adapted for 
use as an antiseptic internally, externally, hypodermically, 
as a douche, a spray, by atomization, and as a deodorant. 
Its application in surgery is unlimited. It is an excellent 
dressing for wounds. It combines the antiseptic virtues of 
benzoic acid, boric acid, oil of peppermint, oil eucalyptus, 
oil wintergreen, oil thyme and thymol. Tablets of Yellow 
Oxide of Mercury, containing two hundredths of a grain of 
the oxide, are a valuable prophylactic against dysentery and 
enteric fever. They prevent fermentation and putrefaction, 
and render aseptic the alimentary tract. Chloranodyne is a 
combination of anodynes, antispasmodics, and carminatives 
which has been widely employed in gastric and intestinal 
troubles. It acts very happily as an anodyne and as an 
astringent in cholera, dysentery, diarrhoea, and colic. 
Antiseptic Liquid arrests decomposition and destroys noxious 
gases that arise from organic matter in sewers and elsewhere, 
and may be used in cellars, barns, outhouses, and the sick- 
room. Antiseptic Tablets are convenient for the extem- 
poraneous preparation of antiseptic solutions of definite 
strength of mercuric bichloride for disinfectant purposes and 



404 miscellaneous medical notes. [March-June, 

for antiseptic sprays. Disinfectant Powder possesses in a 
high degree disinfectant, absorbent, and antiseptic 
properties. It is admirably adapted for the disinfection of 
excreta in cholera, yellow fever, and typhoid fever. Sulphur 
Bricks are effectual in the fumigation and disinfecting of 
rooms after infectious diseases. Ethereal Antiseptic L Soap 
(Johnson's) was devised by an experienced nurse in the 
surgical clinic of the Jefferson Medical College. Its 
marvelous cleansing powers make it a valuable adjunct 
to the armamentarium of the physician and surgeon. 
Mercuric Chloride can be dissolved in it in ordinary propor- 
tions. Parke, Davis & Co. will be pleased to forward, on 
request, any information desired concerning these products. 



Vol. IV. SEPTEMBER, 1893. No. i 



THE REVIEW 



OF 



INSANITY AND NERVOUS DISEASE 



A Quarterly Compendium of the Curreint Literature 
. of Neurology and Psychiatry. 



editor: 
JAMES H. McBRIDE, M. D., 

MILWAUKEE, WIS. 



MANAGING EDITOR: 

G. J. KAUMHEIMER, M. D., 

MILWAUKEE, WIS. 



ASSOCIATE EDITORS: 

Landon Carter Gray, M. D., New York; C. K. Mills, M. D., Philadelphia; 

Eugene Riggs, M. D., St. Paul, Minn.; W. A. Jones, M. D., Minneapolis, 

Minn.; H. M. Bannister, M. D., D. R. Brower, M. D., H. M. Lyman, 

M. D., J. G. Kiernan, M. D., Archibald Church, M. D., 

Sanger Brown, M. D., S. V. Clevenger, M. D., 

Richard Dewey, M. D., Chicago; Frank R. Fry, 

M. D., L. Bremer, M. D., St. Louis; 

Frank P. Norbury, M. D., 

Jacksonville, 111. 

1893. 
Swain & Tate Co., Printers, 

milwaukee. 



INDEX. 



Original Article— Epileptic Insanity, - - 1-20 
By J. H. McBride, M. D. 

Neurological — 

Anatomy and Physiology, - - 21-23, 

Pathology and Symptomatology, 24-42 

Therapeutics, ------ 43 S 2 

Surgery and Traumatic Neuroses, - - 52-61 

Psychological — 

Pathology and Symptomatology, - 62-72 

Therapeutics and Hypnotism, 7 2 ~75 

Editorial, - - . - 76-83 

Asylum and Hospital Reports, - - - 83-84 

Notes and Comments, - - 84-86 

Book Reviews, ------ 86 ~ 8 7 

Pamphlets and Reprints, - 87-90 



i 



The Review 



OF 



Insanity and Nervous Disease. 

FOR SEPTEMBER, 1893. 



EPILEPTIC INSANITY. 

By James H. McBride, M. D., 
[Supt. Milwaukee Sanitarium for Nervous and Mental Disease.] 



The clinical features of Epileptic Insanity entitle it to be 
considered separately, though its manifestations are variable 
as regards the type of disorder. In some cases we observe 
the symptoms of acute mania, in others, occasional but pro- 
nounced depression, and in others dementia. The form of 
disorder doubtless depends upon the degree of dissolution of 
the psychical centers, melancholia being the milder degree, 
mania a greater degree of dissolution, and dementia a more 
serious dissolution still, showing as it does the wreckage that 
is left by repeated storms of convulsion. 

In speaking of Epileptic Insanity, it is necessary to treat 
with some fullness epilepsy itself, for they cannot well be 
separated, the insanity being the reverse side of the epileptic 
picture. 

At the outset we naturally ask, "What is the condition of 
the nerve centers that results in the epileptic fit ?" The view 
which is generally accepted is that the fit is due to a sudden 
and violent discharge of nerve force, which discharge results 
in unconsciousness or convulsions or both. The function of 
the nerve cell is to store up and expend nerve force. In 

Lecture delivered to the students of the Chicago Policlinic, May, '93. 



406 EPILEPTIC INSANITY. [Sept. 

health this discharge is only in response to stimulous, but in 
certain diseased states the cells become morbidly unstable and 
discharge, without a stimulus, violently and suddenly. 
Twenty years or more ago, it was the fashion to consider 
arterial cerebral spasm as the proximate cause of the epileptic 
fit, but this explained nothing, not even itself, and only 
exchanged one pathological puzzle for another. The theory, 
therefore, that epilepsy is primarily a discharge of unstable 
nerve cells is, for the present at least, the most reasonable 
explanation. 

It has been said that this is a theory only and cannot be 
demonstrated, but it accounts for the phenomena and should 
be valued accordingly. We should not despise theories, for 
they are the scaffolding by the aid of which ah science has 
been built and are necessary to progress. We are indebted 
to theories for much of our scientific knowledge in medicine 
and out of it, and though the theories often bear little resem- 
blance to the facts to which they have led, they have at least 
held the lantern for man while he searched. 

What is the cause of the molecular instability of cells that is 
exhibited in the phenomena of epilepsy? One view commonly 
held is that this instabilit}^ is due to some perversion of nutri- 
tion through which the structure of the cells becomes faulty 
and therefore excessively unstable. In this view there is not 
necessarily, a pathological condition demonstrable by the 
microscope, but some failure in the nutritive supply whereby 
the inhibitory power of the higher cortical centers is lost, and 
a morbid instability with involuntary discharge results. 

Dr. Bevan Lewis claims to have found in epilepsy a certain 
pathological condition which, to his view, explains the phe- 
nomena of the disease. This consists in a degeneration of 
the nucleus of the cell which he claims is a constant factor in 
epilepsy. You know that the physiologists teach that the cell 
nucleus in some way presides over the nutrition of the cell 
and also acts as an inhibitory or controlling center of the cell. 
If the nucleus is diseased, the cell fails in the performance of 



1893*] BY JAMES H. MCBRIDE, M. D. 407 

its function and degenerates. Dr. Lewis finds in epilepsy 
degeneration of the nucleus of the cortical nerve-cells and 
this so constantly that he considers that it explains the disease. 
If the nucleus is the inhibitory or controlling center of the 
cell, presiding over its vital changes and its functions, then 
when it is degenerated it is to be expected we would find per- 
version of function, shown especially in irregular, sudden and 
wasteful explosions of energy. Dr. Lewis claims also to have 
found nuclear degeneration in alcoholic insanity, a form of 
disease having many features in common with epileptic insan- 
ity, especially in its explosive nature. 

With this exception there is nothing definitely known con- 
cerning the pathology of epilepsy. The pathological condi- 
tion of the cornu ammonis found in epileptics by Meynert 
and others, has probably no significance whatever. The 
claim by others that there is a morbid over-growth of con- 
nective tissue in chronic epilepsy does not explain the patho- 
logy of the disease as the over-growth of nuroglia is probably 
a result and not a cause of the epilepsy. 

The ruinous effects of the epileptic seizures upon the finer 
structure of the brain is apparent when we consider the deli- 
cacy and fineness of the ultimate anatomical elements, and 
that beside these there are myriads of undeveloped elements, 
waiting in there embryonic state, for the call of function to 
organize their relations, and discipline their powers to deli- 
cate and complex capacity. The violent and brutal discharge 
of the epileptic convulsion not only fills up the well worn 
channels of function, but spreads out as a devastating flood of 
energy over those yet unorganized and delicate nerve tracts 
destroying one by one their fine relations and thus by exhaus- 
tion and repeated disruption of structure checks further 
development of the brain. 

The arrest of growth and the degeneracy thus initiated are, 
if the fits continue, progressive and general. The disappear- 
ance of the nerve tissue proper involves, however, a patho- 
logical necessity, that of the production of some form of tissue 



408 EPILEPTIC INSANITY. [Sept. 

to take the place of that destroyed, and this is the origin 
of the sclerosis in this and other chronic cerebral diseases. 
Connective tissue, of which neuroglia is a special form, is a 
lowly organized tissue having simply the passive function to 
perform of holding together the higher structures. In lower 
animal forms we find relatively more neuroglia in the central 
nervous organs; and as we ascend in the animal series it 
diminishes in proportion as the nerve elements proper 
increase; that is nature gradually learns to dispense with this 
inferior tissue and replaces it with that of higher order. It is 
thus that she is able to pack in the small box of our skulls, 
the fifty precious ounces of structure with the wonderful 
results exhibited in cerebral function. When, however, the 
highly organized tissues, like nerve cells and fibers, dis- 
appear through disease, their complex structure renders their 
reproduction impossible; and so neuroglia having simple 
structure and low organization is produced to fill the place. 
Therefore, we find in the brain of the senile, in those of the 
chronic insane, and in epilepsy there is an overgrowth of 
neuroglia because in the absence of the higher tissues it is 
supplied at a low cost of vitality. The meaning, then, of the 
morbid growth of cerebral neuroglia in epilepsy is that it is 
secondary to cell degeneracy, nature uses it to fill up the 
vacant spaces that decay has made. 

It will be interesting to consider a moment the mechanism 
of the cerebral discharge which is exhibited in epilepsy. If I 
pile a number of bricks on top of each other on this table, 
each brick will, when put in place, represent just the energy 
that I expended in lifting it, and when it falls it will give out 
just that amount of energy in the form of heat, molecular 
motion, atmospheric vibration. In lifting them I stored up 
energy, in their fall this energy was expended. Nerve cells 
?re composed of molecules and atoms, the former being 
aggregations of the latter. The molecules are associated in 
twos and sixes, etc., according to the complexity of the func- 
tioning cell and their relations are subject to incessant change 



l8g3-] BY JAMES H. MCBRIDE, M. D. 409 

to correspond with the processes of function. The invisible 
servants of vitality are ever at work within the nerve cells 
placing these tiny nerve molecules and atoms in complex 
relations and in unstable positions from the fall of which 
nerve energy is set free. That is, the vital processes, when 
they lift them into unstable positions, store up in them the 
energy expended in lifting them, and when upon an appro- 
priate stimulus they fall back as my bricks did into simpler 
compounds, they give out that stored up energy. 

This briefly and imperfectly is the mechanism of normal 
cell action and morbid action conforms to the same law. In 
epilepsy there is this same molecular disruption, a disinte- 
gration of cell structure with the result not as in health of 
orderly and purposeful discharge but of violent and disorderly 
discharge. The path of the discharge varies so that the 
phenomena of epilepsy may be either motor, sensory or 
psychical. Epilepsy then, is a morbid discharge from cells 
which, owing to some abnormal condition, are pathologically 
unstable. 

The different forms of epilepsy may be named as follows: 

Grand Mai, or the ordinary epileptic seizure. 

Petite Mai, or cerebral or mental epilepsy. 

Nocturnal epilepsy. 

Jacksonian epilepsy. 

Epilepsy occurs in connection with other diseases, as 
hemiplegia, syphilis or alcohol, but there is no special form 
of epileptic insanity resulting from these conditions. 

Before proceeding to describe the various epilepsies and 
their resulting mental affections I wish to speak briefly of an 
important accompaniant of epilepsy, the so-called aura epilep- 
lica. This phenomenon is not present in every case of epi- 
lepsy, though it often is. The aura, as you know, is some 
sensation, or motion, or mental impression immediately pro- 
ceeding a fit and announcing its coming. In some cases, there 
is a vague or strange sensory impression, as of some one's 
breath being blown in the face or a sudden sensation of some- 



41 EPILEPTIC INSANITY. [Sept. 

thing passing up the spine or leg to the brain, or it may be a 
twitching or cramping of a muscle or a trembling of some part. 
The aura may start from any part of the body, from the skin, 
organs of sense, or from the internal organs, especially those 
supplied by the vagus nerve. It may involve the special 
sense organs or it may be purely psychical. One patient 
always saw a cat before a fit, others see balls of fire, flashes 
or various colored specks; others hear bells ring, hear roaring 
or voices; others have hallucinations of senses of smell or taste, 
the latter, however, being very rare. In some cases there 
may be a habitual combination of aura affecting two or more 
senses. One patient said to Dr. Reynolds that just before a 
fit he always had a horrible smell of green thunder, a rather 
picturesque description of the involvement of three senses. 
In some patients there is the recurrence of some emotion or 
idea at the oncoming of a fit. In one the same idea always 
occurs, in another a feeling of fright or terror. Pelops, the 
master of Galen, was the first to use the term "Aura;" his 
attention being called to it by patients who referred to a sen- 
sation of vapour passing from some part to the head. Believ- 
ing the arteries to contain air, he suggested that their sensa- 
tion was correct, the vapour passing up the vessels, and he 
called it "spirituous vapor." Statistics show that a little 
more than fifty per cent, of epileptics have an aura. 

Of the two kinds of epilepsy most commonly met with the 
Grand Mai and the cerebral or mental epilepsy are not always 
well demarkated, there being intermediate forms between the 
two extremes; in some cases the fits partake of the character 
of both; some cases begin as one form and pass into the other 
or exhibit both. I had one case under observation in which 
the first attacks were a temporary aphasia only lasting a few 
seconds; later, there was temporary aphasia with mental con L 
fusion but no unconsciousness. A year later there was devel- 
opment of Grand Mai with disappearance of the milder 
attacks. 

It is unnecessary for me to mention the features of the 



1893-] BY JAMES H. MCBRIDE, M. D. 4II 

ordinary epileptic seizure as you are all familiar with it. The 
insanity that results from any of the varieties of epilepsy may 
be, as stated, of different form in different cases. The epi- 
leptic insane may be depressed and morose, subject to delu- 
sions, usually those of persecution and suspicion. Others 
are violently maniacal; others, without showing any of these 
types of disorder, become progressively weak-minded, victims 
of the hopeless epileptic dementia. 

Epileptic dementia is that condition of mental weakness 
which results from epileptic seizures and especially when the 
disease is of long standing. It is not necessarily associated 
with any more active mental derangement, but may and often 
does begin soon after the epilepsy develops and progresses 
to mild or serious loss of mental power. This form of 
dementia while being in the main much like the terminal 
dementia of other insanities, presents in the appearance of 
the patient some distinguishing characteristics, though these, 
I confess, are not easy to convey in words. The bloated 
face and dull, sodden expression, associated with some hesi- 
tancy of speech and mild mental confusion usually suggests 
to the expert an epileptic origin. 

In a very large proportion of chronic epileptics dementia 
in some degree is a concomitant. At first there is the 
slightest dulling of the mental faculties, such as faulty judg- 
ment, a difficulty in grasping what was formerly easy to 
understand, slight failure of memory for recent occurrences, 
some difficulty in fixing the attention, All these indicate a 
slight failure of the mental vigor and are the first steps in the 
long descent of- mental deterioration that ends in hopeless 
obliteration of the mental faculties. 

In the extreme degree of mental degradation that results 
from epilepsy there is but the slightest trace of mind left, the 
patients take on flesh, grow dull and listless and are sluggish 
in movement; the}'' only comprehend the simplest ideas and 
even such with apparent effort. The destruction of the mind 
is as thorough as if the cortex had been cut away. There is 



412 EPILEPTIC INSANITY. [Sept. 

in some of these cases a tragic exhibition of the mild and 
timid manners of a child in their helplessness, with occasional 
explosions of furious and destructive violence. There are 
many cases of epilepsy in which these attacks of violence 
never occur, however. They are timid and hesitating in 
manner, slow of movement, speech and comprehension, good 
natured, easily pleased and childlike. It is one of the most 
forcible as it is one of the saddest exhibitions of the dissolu- 
tion of the brain by disease. 

The mania of epilepsy, from whatever form of fit, is of the 
most furious and violent kind. There is nothing in the round 
of mental disorders that equals in brutal and destructive fury 
the mania of epileptics. They are utterly abandoned to 
raving violence that nothing can check or turn aside for a 
moment. I had a man under my care some years ago whose 
father was an epileptic, whose sister had been insane, and 
who had himself been an epileptic from his fourteenth year. 
At the age of twenty-eight he had one of his usual fits and 
immediately became violent and was under my care during 
its continuance which was about three months. For six 
weeks he was continuously maniacal with the most terrifying 
hallucinations, screaming, crying for help, begging for mercy, 
attacking every one that came into his room, and could only 
be calmed by drugs for a short interval. This maniacal con- 
dition passed away rather suddenly and he afterwards recov- 
ered and returned home to his occupation. This particular 
attack seemed to produce no lasting bad effect upon his men- 
tal faculties and with the assistance of his wife he continued 
in the management of a business that brought him a fortune. 
The epileptic fits had, however, perceptibly weakened his 
mind previously. It is now thirteen years since the attack of 
mania and he has had no return of it though the fits continue. 
This illustrates the fact that is observed in many epileptics 
that there may be an out-break of maniacal violence but 
once in a life time and which may last from a few hours to 
several weeks and the patient may go on having the fits and 



l893«] BY JAMES H. MCBRIDE, M. D. 413 

there not again in years or a long life be a recurrence of 
the insanity 

Epileptic insanity may precede a fit, take the place of a fit, 
or it may immediately follow it, and there are other cases in 
which the insanity occurs in the intervals of fits neither imme- 
diately following nor preceding one. The one most important 
feature of epileptic insanity is the tendency to violent and 
homicidal acts. The epileptic is specially liable to vicious 
and criminal conduct, being irritable, suspicious and impul- 
sive, and hence of all lunatics he is the most dangerous. 
Among the mental perversions preceding a fit may be 
irritability, moroseness and a desire to wander about alone 
refusing usual companionship or occupation. Those who 
are associated with an epileptic are often able to predict a 
fit from this condition. The epileptic will fly into a passion 
about some trivial matter, perhaps become furious and strike 
or violently attack some member of the family. Other cases 
are despondent and some times suicidal for a short time 
before the attack. Others have head-ache, are dull and list- 
less. There are others who for a short time before a lit are 
elated and exalted, loquacious and egotistic and coarse in 
manner and conversation. After the recurrence of the con- 
vulsion there is a return to the usual mental state. The fit, 
therefore, is in some cases the end of a condition of mind 
that is actual insanity or on the border of it, the explosion of 
the convulsion seeming to clear the mind and restore it to its 
normal condition. In some cases a violent attack of tran- 
sient mania seems to take the place of a fit or it may be said 
to be the fit expended in the psychical sphere. The charac- 
ter of the insanity is not modified by its time relation to the 
fit, that is by the fact that it occurs before or after a fit or in 
the interval. 

Miudsley, in his work on "Responsibility in Mental 
Disease," mentions an epileptic who seeing a companion 
asleep in a field seized a stone and crushed his head killing 
him instantly. He then fell down in a stupor in which he 



414 EPILEPTIC INSANITY. [Sept. 

was found by persons passing. Being found an epileptic he 
was sent to an asylum and while there almost succeeded in 
killing an attendant. Echeverria mentions a patient of a 
particularly gentle and affectionate disposition who arose in 
the morning after having a fit in the night, walked into his 
brother's room and after pacing the floor excitedly, seized a 
razor and cut his own throat quite seriously. On another 
occasion while at breakfast with his sister, upon her asking 
him if he would have some coffee, he rushed upon her and 
attempted to injure her. His brother, coming to the sister's 
assistance, found the patient leaning on the back of a chair 
with a knife in his hand unconscious in an attack of petite mal. 
Such illustrations might be multiplied indefinitely. 

There is a condition called epileptic automatism which is not 
infrequently associated with the disorder and which is of 
great interest. Some observers hold that this automatism is 
only observed as a sequel to a fit, others that it may replace 
a fit. Further observation is necessary to settle this point. 
In cases where epileptic automatism is shown it certainly 
most usually develops after a fit. In some cases there is a 
manifestation of it after a fit in the way of doing simple but 
incongruous or silly things. For instance one patient always 
attempted to undress, and if allowed to do so would attempt 
to put his clothing on again, but was apt to mistake his coat 
for his pants or his shirt for his coat. Other patients run 
about kissing those they meet even strangers or even articles 
of furniture. Others steal and hide things or pick pockets 
with great cunning. There is no subsequent recollection of 
any of these acts. Echeverria mentions a boy who took a horse 
and buggy he found in the street, and after driving for some 
time left it at a stable saying it was his. There was no sub- 
sequent recollection of his having done this. He mentions 
another epileptic who enlisted as a sailor in New York, and 
suddenly recovered consciousness in mid ocean while the 
vessel was sailing for London. There are many instances 
where epileptics in this state have stolen and concealed 
articles, have committed homicide, arson, etc. 






l893-] BY JAMES H. MCBRIDE, M. D. 415 

A satisfactory explanation of this condition is perhaps not 
possible. It has been said that in this state the patients are 
unconscious, and in a sense this is probably true. It is con- 
sciousness perverted and acting on a lower plane, a plane too, 
on which normal consciousness cannot act. Consciousness is 
a variable quantity, there being many degrees of it in the 
normal state, from those processes that lie upon the border- 
land of sleep to those that play clear and vigorous in our most 
active mental operations. Morbid conditions degrade the 
order of normal mental processes and they do this by involv- 
ing first the higher processes, that is those that are more 
complex, more delicate, more unstable, more easily disinte- 
grated by disease. The result of this degradation of the 
highest structures is that the lower orders of association 
become aclive and the mental processes that are shown, are 
the exhibition of the brain working upon an inferior level, 
producing a consciousness of an inferior order. The lower 
levels or orders of mental action are those of instinctive acts, 
in which self control is weakened or destroyed. These acts 
may be purposeless or silly or they may be in the line of 
animal gratification, or criminal, as pilfering or homicide, 
These instinctive tendencies exist potentially in every mind 
and when disease weakens the higher faculties that hold these 
tendencies in check then they act without restraint. 

Concerning epileptic automatism it is important to remem- 
ber that during its continuance there may be apparently sane 
and conscious acts of an intelligent and complex nature per- 
formed; there may be apparently intelligent conduct extend- 
ing over several hours or days involving conversation, busi- 
ness transactions, traveling long distances, crimes committed, 
etc., and all this done when the patient is in an abnormal 
mental condition and of which he will on recovery have no 
recollection whatever. 

The mental condition of epileptics during the intervals of 
the fits is by no means constant. Some are normal or nearly 
so between the fits, others showing various degrees of 



416 EPILEPTIC insanity. [Sept. 

derangement. Some authors hold that it is in only a minority 
of cases that there is any mental failure in chronic epilepsy. 
This is not in harmony with my own experience, and the best 
recent authorities deny its correctness. My personal obser- 
vation is that epilepsy almost always produces some mental 
impairment and in the majority of epileptics the impairment 
is decided. It is surprising how quickly the mind suffers 
from epilepsy in some cases. One young man who developed 
epilepsy from long over work came to me within three months 
after having had his first fit, and yet he could see himself that 
his mental vigor was distinctly impaired. There are some 
chronic epileptics who attend to business sucessfully. and who 
to an untechnical observer would appear perfectly well and 
yet who have suffered considerable mental impairment. It is 
probable that you are all acquainted with such cases. The 
members of one's family are not always competent judges of 
the mental condition of an epileptic, as the mental deteriora- 
tion is often so slow that their associates fail to note it. 

There are other epileptics, who, while not showing actual 
insanity, show some departure from the normal state; they 
are irritable and morose in the intervals of the fits, showing 
lack of normal sympathy and affection for relatives, lack of 
interest and ambition in occupation. Others, in whom the 
disease has made more progress, are subject to fits of passion 
or attacks of violence, or of delusions of suspicion and per- 
secution. 

Some epileptics may be quite orderly in their conduct and 
yet entertain delusions of persecution, making them dangerous 
to others ; they may, however, and often do conceal their 
delusions, because they are suspicious and fear to confide in 
any one. 

Epileptics are not infrequently morbidly self-conscious, 
having exaggerated ideas of their own importance and feeling 
themselves unappreciated and neglected. The epileptic, in 
this condition, is usually selfish and self-centered in all his 
plans ; his interest is wholly in himself and his imaginary 



l8g3-] BY JAMES H. MCBRIDE, M. D. 417 

troubles. Being irritable and suspicious, he is on the look- 
out for slights and neglects; he misinterprets remarks and 
acts of others into intentional insults and builds extravagant 
delusions of personal wrong and insult upon the most inno- 
cent and trivial acts of others. They will lie in regard to 
their treatment by others, make false accusations of ill treat- 
ment and exhibit self-inflicted bruises as evidence of the 
truth of their statements. Women will accuse husbands of 
immoral conduct and tell the most circumstantial and plausi- 
ble stories of outrages attempted upon them. The lower 
grade of epileptics will show these characteristics with less 
artifice and less success at deceiving. The moral perversion 
of some of them is extreme, especially in regard to the sexual 
propensities, soliciting improper attention from men or other 
women in the most open and shameless manner. 

In mental or cerebral epilepsy there is as the only outward 
indication of the fit, often .a sense of vertigo and faintness 
with facial pallor; in others there is no vertigo, but pallor and 
twitching of facial muscles; in others temporary confusion 
and a momentary pause in work or conversation. The men- 
tal processes are temporarily arrested, the patient, if busy, 
stops for a moment and then takes up the conversation or 
work. In some cases there is a vacant stare for a moment 
with a lapse of consciousness. 

A French jurist was subject to these attacks and would 
leave his seat in court, walk out of the court room, wander 
about for a few moments and return and continue his duties. 
Following these attacks there may be and often are periods 
of confusion or insanity lasting from a few minutes to days 
and during their continuance patients may wander away from 
home, steal and hide various articles, or under the influence 
of hallucinations commit homicide or arson. Some epileptics 
during this stage desire to kill some one or set fire to build- 
ings. A patient of mine said one of his first morbid fancies 
was that he must burn the church building in which he 
officiated as pastor and he actually tried to do it twice but 



418 EPILEPTIC INSANITY. [Sept. 

failed. In the only attack I saw him have he became violent 
and remained so for half an hour. Naturally he was a gentle 
and mild mannered man. 

Following these attacks there may be perfect lucidity and 
continuance of usual occupation or there may be confusion or 
mental derangement. The patient may wander away from 
home, commit thefts or other crimes such as I have already 
detailed. A man was under my care some time ago who had 
been from boyhood subject to cerebral epilepsy. He was 
considered harmless and lived at home. One day he sud- 
denly became furious and killed both his parents with an ax. 
He refused to give any explanation of the crime, but there is 
no doubt that he did the act in an attack of epileptic fury. 
These seizures that last only a moment and may pass 
unnoticed for a long time may be followed by attacks of the 
most furious violence. Lewis mentions a man who, during 
the night, thought he saw two burglars attacking his wife 
and he ran for a hatchet. He remembered nothing after that 
but was subsequently found wandering in the street with a 
bloody hatchet in his hands with which he had killed his 
wife. It was believed he had a hallucination during an 
epileptic seizure and had killed his wife thinking he was 
attacking a burglar. These attacks are sometimes associated 
with unpleasant or even terrifying hallucinations that drive 
the victim to fury and violence. The patient sees some one 
striking at him with a knife, he hears some horrible accusa- 
tion from an enemy and becoming desperate he rushes upon 
and attacks the first person he meets. In this state a man 
ran through the streets in New York some years ago stabbing 
every one he met, seriously injuring several persons. This 
form of epilepsy may precede the usual Grand Mai f orm or it 
may replace it or occur in the intervals of other fits. Some 
have Grand Mai at rare intervals and cerebral epilepsy more 
frequently. This latter form of epilepsy causes more rapid 
failure of the mental powers than any other kind of fit. Fit- 
ful brilliancy of mental powers has been associated with this 



1893-] BY JAMES H. MCBRIDE, M. D. 419 

form of epilepsy. Swedenborg and Mahomet who were both 
subject to this^nd the usual form of the attack are instances. 
The extravagance and visionary character of their belief is in 
harmony with the self-centered consciousness of the epileptic 
whereby he magnifies his personality and exaggerates all 
impressions, being especially subject to hallucinations of the 
senses. 

Nocturnal Epilepsy may be either the grand mal or mental 
epilepsy. It is thus named, of course, from its occuring at 
night and it may exist for a long time unsuspected by patient 
or friends. Some years ago I was called to see a little boy 
of nine years who had for some time and on many occasions 
attacked his younger brother while they lay in bed at night. 
Repeated punishing having done no good and the boy showing 
some mental peculiarities, they requested me to examine him. 
I learned he sometimes complained of headache on the day 
following the scenes with his brother and was dull and indis- 
posed to play and also alleged he had no recollection of hitting 
his brother. His mother stated that he passed his urine in 
bed quite frequently. Suspecting epilepsy, I had him watched 
and my suspicions were confirmed. Some months later he 
had attacks during the day of cerebral epilepsy and was 
invariably violent afterwards. He became an epileptic imbe- 
cile, his mental development being arrested by the fits, and is 
now, at nineteen years of age, in an asylum. His younger 
brother afterwards had epilepsy, though I do not know the 
form of the disease in his case. 

The Nocturnal Epileptic fit may occur without waking the 
patient from sleep. Sometimes there is the initial cry and 
convulsions, at other times these are not observed and in some 
cases they are never observed. The patient, however, is 
almost certain to have morning headache, feeling dull and 
probably irritable. The face will be flushed or bloated with 
minute petechia? on face and neck, and sometimes with sore 
tongue, the result of its having been bitten during the fit. 
The urine is not infrequently passed in bed at the time of the 



420 EPILEPTIC INSANITY. [Sept. 

fit. Stains of blood and saliva are also occasionally found 
and are important confirmatory evidence of a fit. Nocturnal 
Epilepsy is very injurious to the mental faculties, and especiallly 
in children it produces early arrest of mental development. 
All forms of epilepsy are much more injurious to children than 
adults. The delicate and imperfectly organized cerebral 
structure is rapidly impaired in function and arrested in growth 
by the violent and repeated shocks of the fit. Epileptic som- 
nambulism occasionally follows the nocturnal seizure and in 
fact all the phenomena observed to follow the diurnal fit may 
be observed in these. Patients attack others sleeping with 
them or in an adjoining room, or get up and walk some dis- 
tance performing apparently intelligent and conscious acts and 
return to bed without regaining normal consciousness. 
Trousseau suggested that all nocturnal accidents should sug- 
gest epilepsy. Morel, Echeverria and others have published 
many cases in which nocturnal epilepsy had led to crime. 

There are some characteristics of the epileptic insane that 
I have thought would be more easily remembered if considered 
separately from the general description. 

An important characteristic of the epileptic is his impulsive- 
ness. There is more danger from the impulsiveness of the 
epileptic than from his intellectual derangement. Of all 
classes of the insane, they are the most impulsive. The fits 
weakening their control and leaving their nerve centers hyper- 
sesthetic and irritable, they react quickly and without thought 
to all impressions. Their mental reflexes are exaggerated 
and their self-control weakened. They are then controlled by 
feeling and passion and their acts are sudden and instantan- 
eous. Combine with this their characteristic suspiciousness 
and you have about as dangerous a person as can be imagined. 
This mental irritability is especially marked at about the time 
of a fit and the utmost tact is necessary in their management. 
This characteristic of epilepsy was impressed upon me in my 
early experience in an insane hospital when one day I placed 
my hand on an epileptic's shoulder, intending to speak to him; 



l8g3-] BY JAMES H. MCBRIDE, M. D. 421 

he turned and struck me, however, in the face before I could 
speak. Instantly he regretted his act, saying he struck with- 
out thinking or even knowing there was any one to strike. 
At such a time, an abrupt remark or a touch or some one 
entering the room suddenly will cause an attack of violence. 
A case has been reported in which an epileptic shoe-maker 
attacked with a shoe knife and seriously injured his little 
daughter who suddenly entered the room where he was. He 
had no recollection of the attack. Epileptics having ideas of 
suspicion in the intervals of the fits are apt to have them 
exaggerated at or about the time of seizures and this, together 
with their irritability and impulsiveness, render them dan- 
gerous at such times. 

The memory of epileptics is often impaired or confused. 
Very many have no recollection of a fit and though mental 
derangement may succeed a fit and last for hours and days 
during which the patient may do complex and apparently 
intelligent acts, yet there may be no subsequent recollection 
of it. This unconsciousness associated with epilepsy is 
important to have in mind because of its medico-legal rela- 
tions. Again the memory of an epileptic of a criminal or 
other act may vary. In some cases there is for a short time a 
partial or confused memory of the occurrences of the abnor- 
mal state and then in a few hours this may be replaced by 
complete oblivion of the occurrence. The statement, there- 
fore by an epileptic that he had no recollection of an occur- 
rence and at another time that he had a confused recollection 
may both be true. This of course rarely occurs but there are 
said to be undisputed instances of it. 

Much has been written in regard to the religious character 
of epilepsy and it is indeed a strange phenomenon. Many 
epileptics are obtrusively religious, saying their prayers where 
they are observed, declaring their moral superiority to others, 
carrying their bible in their hands and reading it where the}' 
are noticed; and these patients are apt to be the most trying 
cases of epilepsy, egotistic in the extreme, wholly absorbed 



422 EPILEPTIC INSANITY. [Sept. 

in self, deceitful, treacherous and quarrelsome, addicted to 
grossness in conduct and language. Dr. Gowers has pub- 
lished a case in which an epileptic girl had visions of being in 
heaven and seeing and talking with persons there. Such 
experiences remind us of those of Swedenborg and Mahom- 
met both of whom were epileptics. 

The medico-legal relations of epileptic insanity are impor- 
tant. How far should the existence of epilepsy render a 
person irresponsible? While some general principles may 
be laid down for the guidance of the physician, no rules 
applicable to all cases can be established. Each must be 
carefully studied and judged by its special indications. 
There are some epileptics in whom the mind is unimpaired 
and these of course could not be considered irresponsible 
except during a fit. There are others in whom there is a 
slight shade of mental failure, some blunting of the normal 
acuteness but with no delusions. Others again are, at or 
about the time of a fit, irritable, suspicious, and perhaps des- 
pondent and morose, showing noticable mental weakening 
yet in the intervals of the fits pass for normal persons. 
Others again have delusions and yet others have paroxysms 
of violence. Epileptics who commit crimes are usually 
chronic cases. While there are exceptions to this rule they 
are rare. We would expect this to be so, for the longer 
the epilepsy has existed, the greater the mental degen- 
eration. Crimes are some times committed at the time 
of a fit but more often in the intervals of fits. The Roman 
law exempted all epileptics from responsibility for three days 
before and three days after a fit. All criminal acts committed 
by epileptics should lead to a careful investigation of their 
mental condition at the time of the act. Some people have 
fits infrequently and are apparently normal in the intervals. 
A crime committed during such interval would not neces- 
sarily be due to the epileptic condition. The nearer, there- 
fore, the act is to an epileptic fit, the greater the chances that 
it was the result of the fit. The nature and manner of the 



l8g3-] BY JAMES H. MCBRIDE, M. D. 423 

crime may help to determine the condition. A crime, if 
apparently motiveless, reckless and furious, is probably due 
to epileptic insanity if committed by an epileptic. 

As we have seen in the case of the man who killed his wife, 
a crime may be committed under the influence of a hallucina- 
tion. Some years ago, in New York city, a man by the 
name of McDonald choked to death his brother with whom 
he was sleeping. He would give no explanation of the 
crime. Some weeks alterwards while in prison he attempted 
to choke another person who slept in the same cell. The 
superintendent of the City Insane Asylum being asked to 
examine him recognized in him an old epileptic patient whom 
he had discharged from the asylum some months before. 

Epilepsy is relatively common among criminal classes and 
also among those who drink. Crimes, when committed by 
them not otherwise explainable should be examined for 
evidences of epilepsy. 

The important features of epileptic insanity may be sum- 
marised as follows: 

1. The forms or varieties of epilepsy liable to lead to 
insanity are the ordinary, Grand Mai, Mental Epilepsy, Noc- 
turnal Epilepsy. 

2. Nocturnal epilepsy and mental or cerebral epilepsy 
produce more rapid mental deterioration than other varieties. 

3. Epileptic insanity may precede, take the place of, or 
follow a fit. 

4. It may be a quiet type of insanity or the most violent 
mania. 

5. The mania may occur only once in the course of the life 
of an epileptic who has the disease from childhood. 

6. Epileptic insanity is a most dangerous form of mental 
disorder as the subject of it is suspicious, irritable, and 
impulsive being conspicuously weakened in self-control. 

7. There is usually loss of memory of events of the insane 
period though occasionally there may be a confused recol- 
lection. 



424 EPILEPTIC INSANITY. [Sept. 

8. That a condition of mental automatism may follow ar 
epileptic fit which may last for days during which a persor 
may transact business, buy a ticket and travel distances, con- 
verse intelligently, and yet afterwards have absolutely, nc 
recollection of anything that occurred during the period. 

9. The epileptic attacks may occur during sleep and noi 
during the waking state, and that this nocturnal epilepsy is 
apt to be associated with violence and ultimate menta 
weakness. 

10. That insanity is more apt to be associated with the 
mild fits called cerebral or mental epilepsy than those ir 
which the convulsions are violent. It must not, therefore, be 
thought that the condition is a trifling one and the danger o 
mental disorder slight because the fits are apparently mile 
and of short duration. 



TRANSLATORS AND ABSTRACTORS. 



ENGLISH. 

T. H. Hay, M. D., Milwaukee, Wis. 
B. M. Caples, M. D., Wauwatosa, Wis. 
T. W. Bishop, M. D., Chicago, III. 

ITALIAN. 
H. M. Bannister, M. D., Chicago, III. 

GERMAN. 

G. J. Kaumheimer, M. D., Milwaukee, Wis. 
Frank P. Norbury, M. D., Jacksonville, III. 
H. M. Bannister, M. D., Chicago, III. 
Jos. Kahn, M. D., Milwaukee, Wis. 

DUTCH 
William Sweemer, M. D., Milwaukee, Wis. 

FRENCH. 
J. G. Kiernan. M. D., Chicago, III. 

SPANISH. 
H. M. Brown, M. D., Milwaukee, Wis. 

SWEDISH, DANISH AND NORWEGIAN. 

Haldor Sneve, M. D., Minneapolis, Minn. 



22 NEUROLOGICAL. [Sept. 



NEUROLOGICAL 



ANATOMY AND PHYSIOLOGY. 



On the Physiology of the Auditory Nerve and its End- 
Organs. — In an article on this topic Griitzner states, from a 
review of the literature of the subject, that the semi-circular 
canals, with their ampullae, are organs for the perception of 
circular motion. J. R. Ewald (Strassburg) has lately found 
that animals in which the trunks of the auditory nerves were 
divided developed a peculiar weakness and clumsiness of 
muscular movement. They do not get dizzy upon being 
rapidly rotated, neither does nystagmus develop under such 
circumstances. Ewald has also found that pigeons from 
which he had removed the entire auditory apparatus, on both 
sides, could hear. This would indicate that the trunk of 
the acoustic nerve is, in these animals, directly sensitive, in 
contradistinction to the optic nerve. Ewald divides the end- 
organs of the auditory nerve into an auditory and a tonus 
labyrinth. He considers the otoliths to be organs for the 
recognition of equilibrium and progression and, secondarily, 
for the regulation of muscular tonus. The perception of 
our position to the horizon is, however, due to both the 
otoliths and the semi-circular canals. Fishes and frogs from 
which the labyrinth has been removed will float for a long 
time on their back or assume other unwonted attitudes. 
Kreidl has also found, latety, that deaf mutes suffer from 
vertigo and nystagmus upon rotation to a much less degree 
than normal persons. Their powers of balancing (e. g. : 
standing on one foot with eyes closed) was also less. 
(Deutsch. Med. Wochensch., No. 6, 1893.) 

G. J. KAUMHEIMER. 



1893]- ANATOMY AND PHYSIOLOGY. 23 

The Respiratory Center in the Medulla. From experi- 
ments made by himself and Mareniscu, Gad has been led to 
the following conclusions: i. The point of the calamus 
scriptorius may be designated, in accordance with Flouren's 
suggestion, as a "noeud vital," but this vital point must not 
be confounded with the bulbar respiratory center. The 
sudden cessation of respiration and death following injuries 
at this point are due partly to the excitation of inhibition- 
impulses and partly to the interruption of conduction between 
the bulbar respiratory center and the spinal motor respiratory 
centers. 2. The motor spinal respiratory centers are repre- 
sented by segmentally arranged cells in the anterior gray 
columns ; they have no especial sensibility to the haemic 
irritation and are not coupled for synergistic action by appro- 
priate connections. They can carry out slight coordinated 
spinal reflexes. 3, The descending paths which synchronize 
the activity of